Maintain · The Chapter 331 program of record
Annual Workplace Violence Program Reviews
Compliance with Texas HSC Chapter 331 is not a one-time project. The statute builds in an annual plan evaluation reported to the governing body; the Joint Commission requires an annual worksite analysis and annual training; and OSHA Publication 3148 calls for periodic program evaluation. The obligation renews by law every year — which is exactly what the Annual Compliance Subscription is built to carry.
VIGILO converts that recurring obligation into a managed program of record: the annual plan evaluation prepared and documented to your governing body, quarterly committee support and minutes, an annual worksite-analysis refresh, an annual training refresh with roster reconciliation, incident-log review and trend reporting, and regulatory-update memos when a statute or standard changes.
The single most overlooked statutory step is the annual evaluation reported to the governing body — completed by the committee but never documented to the board. This subscription makes it a calendared, documented event every year. Pricing is a flat annual subscription, never per-incident or percentage-based.
What you receive
What the engagement includes
Every deliverable is documented the way a surveyor reads it — and assembled to drop straight into your survey-readiness binder.
Annual plan evaluation + board report
Prepared for, and documented to, your governing body — every year.
Quarterly committee support + minutes
Keeps the program demonstrably active through the year.
Annual worksite-analysis refresh
With a maintained mitigation log, so the analysis never goes stale.
Annual training refresh
With rosters reconciled against your full census.
Incident-log review + trend report
Tracking, trending, and leadership review on a fixed cadence.
Regulatory-update memos
When a statute or standard changes, your plan is updated.
Speaking the language of surveyors
The six questions a surveyor will ask — answered
Surveyors follow a tracer: they pull the thread from policy to plan to committee to training to record to corrective action. This module is organized around exactly what they ask, what they review, and what gets a facility cited.
What surveyors ask
- Show me that the committee evaluated the plan and reported the results to the governing body in the last 12 months.
- Show me your committee meeting minutes for the last year.
- When did you last complete your annual worksite analysis, and what did it change?
- Show me records that staff were trained at least annually — and that the roster is current.
- How do you keep the program current when the statute or a standard changes?
What surveyors review
- The annual plan-evaluation record and proof it was reported to the governing body.
- Committee meeting minutes across the trailing twelve months.
- The current worksite analysis and the mitigation log closing its findings.
- The annual training roster, reconciled against the full census.
- Incident-log review and trend reports with evidence of leadership review.
Required documentation
| Document | Why surveyors want it |
|---|---|
| Annual plan evaluation + governing-body report | The statutory recurring obligation, renewed every 12 months (HSC Ch. 331) |
| Quarterly committee minutes | Proves the committee meets and acts through the year |
| Refreshed annual worksite analysis + mitigation log | Keeps the TJC worksite-analysis expectation current |
| Annual training refresh roster | Satisfies the at-least-annual training cadence |
| Incident-log review + trend report | Tracking, trending, and leadership review on a fixed cadence |
Common deficiencies
- The annual evaluation done but never reported to the governing body — the single most overlooked statutory step.
- A program built once and left to go stale between surveys, with no scheduled review.
- A worksite analysis completed once and never repeated annually.
- Training that lapses because no one owns the annual cadence.
- Incident data collected but never trended or seen by leadership across the year.
How to prepare
- Put the annual plan evaluation on the calendar and make the governing-body report a permanent agenda item.
- Schedule the worksite analysis and training refresh on a fixed annual cadence.
- Maintain quarterly committee minutes and a living mitigation log.
- Produce a quarterly incident trend report that visibly reaches leadership.
- Track regulatory changes so the plan is updated when a statute or standard moves.
How VIGILO helps
The Annual Compliance Subscription converts the statute’s annual obligation into a managed, recurring program of record. The annual evaluation to the governing body (Texas), the annual worksite analysis and training (Joint Commission), and the periodic program evaluation (OSHA) all renew by law every year — which is exactly what this subscription carries:
- The annual plan evaluation prepared for, and documented to, your governing body — every year.
- Quarterly committee support and minutes, keeping the program demonstrably active.
- An annual worksite-analysis refresh and a maintained mitigation log.
- An annual training refresh, with rosters reconciled against your census.
- Incident-log review, trend reporting, and regulatory-update memos when a statute or standard changes.
Primary sources
Sources: Texas Health & Safety Code Chapter 331 (SB 240, 88th Leg., 2023); 26 TAC §133.55; HHSC Provider Letter PL 2024-10; The Joint Commission Workplace Violence Prevention requirements (effective Jan. 1, 2022 for hospitals); OSHA General Duty Clause §5(a)(1), OSHA Publication 3148 and CPL 02-01-058.
Where this fits
Related services
Every VIGILO engagement maps to the same surveyor-fluent framework, so the pieces fit into one connected program of record.
Workplace Violence Prevention Programs
The complete, facility-specific program of record — committee, plan, training, and binder.
Flat fee · $2,500–$6,000
Details →Healthcare Staff Training
Instructor-led training tied to the statutory annual cadence and documented for your survey file.
$1,500–$2,500 / training day
Details →Workplace Violence Risk Assessments
A documented environment-of-care worksite analysis, written the way a surveyor reads it.
Flat fee · scoped per engagement
Details →Tuned for your facility: Hospitals, Long-Term Care & Nursing Facilities, Home Health & Hospice (HCSSA). See all facilities →
Annual Program Reviews FAQ
Frequently asked questions
Why is workplace violence compliance an annual obligation, not a one-time project?
Because the obligation renews by law every year. Texas HSC Chapter 331 requires an annual plan evaluation reported to the governing body; the Joint Commission requires an annual worksite analysis and annual training; and OSHA Publication 3148 calls for periodic program evaluation. A program built once goes stale between surveys. The Annual Compliance Subscription carries the recurring cadence so it never lapses.
What does the Annual Compliance Subscription include?
It runs the annual plan evaluation and the governing-body report, quarterly committee support and minutes, an annual worksite-analysis refresh, an annual training refresh with roster reconciliation, incident-log review and trend reporting, and regulatory-update memos when the statute or a standard changes — your Chapter 331 program of record, maintained.
How is the subscription priced?
It is a flat annual subscription of $1,500–$3,600 per year per site, never per-incident or percentage-based. It converts the statute’s annual obligations into a single managed engagement, so the recurring work is owned rather than rediscovered each survey cycle.
What is the most overlooked recurring step?
The annual plan evaluation reported to the governing body. Many facilities complete the committee’s annual review but never document that the results were reported to the board — a distinct statutory obligation that surveyors check and that becomes evidence in post-incident litigation discovery. The subscription makes it a calendared, documented event every year.
Find out exactly where your facility stands
A Survey-Readiness Audit scores your committee, plan, training, and governing-body reporting against Chapter 331, the Joint Commission, and OSHA — in one document.