Healthcare WVP Compliance Glossary

Glossary definitions

26 TAC §505.55

The Texas HHSC administrative rule that implements Chapter 331 for general and special hospitals, and what a hospital licensure surveyor checks against. It was adopted in October 2024 as 25 TAC §133.55 and renumbered to 26 TAC §505.55 effective January 31, 2025.

26 TAC §508.31

The Texas HHSC rule that implements Chapter 331 for ambulatory surgical centers. It was adopted in October 2024 as 25 TAC §135.31 and transferred to 26 TAC §508.31 effective January 31, 2025.

26 TAC §509.70

The Texas HHSC rule that implements Chapter 331 for freestanding emergency medical care facilities, effective October 21, 2024.

26 TAC §510.47

The Texas HHSC rule that implements Chapter 331 for private psychiatric hospitals and crisis stabilization units (the mental hospitals licensed under HSC Chapter 577), effective October 21, 2024.

26 TAC §511.79

The Texas HHSC rule that implements Chapter 331 for limited services rural hospitals, adopted September 19, 2025 and effective October 9, 2025.

26 TAC §554.1920

The Texas HHSC nursing facility rule on operating policies and procedures. As amended effective September 18, 2024, it requires a nursing facility to have a workplace violence prevention committee and to develop workplace violence prevention policies and procedures in accordance with HSC Chapter 331.

Abatement

The corrective action and deadline OSHA requires to fix a cited hazard.

Annual Plan Evaluation

The yearly committee review of the WVP plan, reported to the governing body, a statutory recurring obligation.

Anti-Retaliation

Protection prohibiting discipline or discrimination against staff who report violence in good faith, including non-discouragement of contacting law enforcement.

ASC

Ambulatory Surgical Center: a covered facility class under Ch. 331.

Condition of Participation (CoP)

A CMS requirement for Medicare/Medicaid participation; there is no standalone WVP CoP, but WVP failures can surface under patient-safety, environment, governing-body, and QAPI CoPs.

CPL 02-01-058

OSHA’s enforcement directive for investigating workplace-violence hazards.

CSHO

OSHA Compliance Safety and Health Officer: the inspector who conducts an OSHA investigation.

De-Escalation

Verbal and behavioral techniques to reduce a person’s agitation before it becomes violence; a core training topic.

EC (Environment of Care)

The TJC standards chapter where the hospital worksite-analysis and incident-tracking WVP requirements were introduced in 2022; for hospitals and critical access hospitals they now sit at NPG.02.04.01 EP 3 and NPG.11.01.01 EP 3.

Element of Performance (EP)

The specific, scorable sub-requirement under a TJC standard; EP numbers changed for hospitals on Jan. 1, 2026 (now NPG.02.04.01 EPs 1 to 3), so cite the current numbering from the free 2026 National Performance Goals chapter.

Environment of Care (EOC) Security Risk Assessment

A compliance-framed assessment of the physical environment’s WVP vulnerabilities; VIGILO’s offering, never a guard/patrol service.

FSED

Freestanding Emergency Medical Care Facility: a covered facility class under Ch. 331.

General Duty Clause

OSH Act §5(a)(1): the legal basis OSHA uses to cite workplace violence where no specific standard exists.

Governing Body

A facility’s board/leadership authority; Ch. 331 requires the annual plan evaluation to be reported to it.

Hazard Alert Letter

An OSHA letter flagging a recognized hazard (common in healthcare WVP, where no specific standard exists) short of a formal citation.

HCSSA

Home & Community Support Services Agency: an agency licensed under HSC Chapter 142; since SB 463, covered by Ch. 331 in every service category (not only home health) when it employs ≥2 RNs.

HR (Human Resources)

The TJC standards chapter where the hospital WVP training requirement was introduced in 2022 (HR.01.05.03 EP 29); for hospitals and critical access hospitals it now sits at NPG.02.04.01 EP 2.

HSC Chapter 331

The Texas Health & Safety Code chapter (added by SB 240, 2023) that requires covered healthcare facilities to adopt and maintain a WVP plan; the core mandate VIGILO serves.

ICF/IID

Intermediate Care Facility for Individuals with an Intellectual Disability: a facility licensed under HSC Chapter 252. SB 463 added ICF/IIDs to Chapter 331, with compliance required since September 1, 2026.

Joint Commission (TJC)

The leading healthcare accreditor; its WVP requirements (effective Jan. 1, 2022 for hospitals; now National Performance Goal #2a) were introduced across the EC, HR, and LD chapters.

LD (Leadership)

The TJC standards chapter where the hospital designated-WVP-leader requirement was introduced in 2022 (LD.03.01.01 EP 9); for hospitals and critical access hospitals it now sits at NPG.02.04.01 EP 1.

NPG.02.04.01

The Joint Commission citation scored for hospital and critical access hospital workplace violence prevention since Jan. 1, 2026: Elements of Performance 1 to 3 under Goal 2, with incident monitoring at NPG.11.01.01 EP 3. The accreditor’s public label for the topic is National Performance Goal #2a.

OSHA 300 Log

The federal injury-and-illness recordkeeping log (29 CFR 1904); serious assault injuries are recordable and are cross-checked against the WVP incident log.

OSHA Publication 3148

OSHA’s “Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers,” organized around five program components.

PL 2024-10

The HHSC Provider Letter (issued April 18, 2024) applying Chapter 331 to HCSSAs that employ two or more RNs. It predates SB 463, under which every HCSSA service category is covered, not only home health.

PL 2026-13

The HHSC Provider Letter (issued July 25, 2026; revised August 10, 2026) on Chapter 331 for intermediate care facilities (ICF/IID), which SB 463 brought under the statute. It applies a hold-harmless period for the physician committee seat from September 1, 2026 to August 31, 2027.

Plan of Correction (POC)

The facility’s written, dated remediation plan submitted after a survey deficiency.

Post-Incident Response

The support owed after an event: Ch. 331 requires the facility to offer immediate post-incident services, including any necessary acute medical treatment, and its plan must adjust patient care assignments to the extent practicable; debrief and EAP referral are common ways to deliver the follow-up and support the Joint Commission also expects.

QAPI

Quality Assessment and Performance Improvement: the CMS-required improvement program where WVP trending can live.

R3 Report

TJC’s “Requirement, Rationale, Reference” publication. Issue 30 announced the 2022 hospital WVP requirements; it has since been retired, and those requirements now sit under National Performance Goal #2a (Preventing Workplace Violence) under Accreditation 360, effective Jan. 1, 2026.

RFI (Requirement for Improvement)

A TJC finding of non-compliance the facility must correct.

SAFER Matrix

TJC’s scoring grid that rates a finding by likelihood of harm and scope (limited/pattern/widespread).

SB 240

The 2023 Texas Senate bill that created HSC Chapter 331.

SB 463 (89th Legislature, 2025)

The Texas bill, effective Sept. 1, 2025, that expanded HSC Chapter 331 from six covered facility classes to eight: it struck the home-health limitation on HCSSA coverage and added ICF/IIDs and state supported living centers, with a Sept. 1, 2026 compliance deadline for the newly covered.

State Supported Living Center (SSLC)

A state-operated residential facility for people with intellectual and developmental disabilities, as defined by Health and Safety Code §531.002. SB 463 added state supported living centers to Chapter 331, with compliance required since September 1, 2026.

Statement of Deficiencies

The official document listing findings from a licensure or CMS survey (the CMS form is the 2567).

Tracer Methodology

The survey technique of following a patient, incident, or staff member through the system to test whether documentation matches practice.

Workplace Violence Prevention (WVP)

A program of policies, committee oversight, assessment, training, reporting, and post-incident response designed to reduce violence against healthcare workers and document compliance.

Worksite Analysis

A proactive assessment (records + walkthrough + employee input) of WVP hazards; required annually by TJC and recommended as Component 2 of OSHA Pub. 3148, which is advisory.

WVP Committee

The standing committee Ch. 331 requires, which must include an RN providing direct care, a physician providing direct care (the only statutory exemption is an HCSSA with no such physician on staff), and a security-services employee (if any and if practicable).

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