Build · The written plan & policies
Workplace Violence Policy & Plan Development
The written, facility-specific WVP plan is the spine of the binder — every other artifact (committee, training, incidents, evaluation) hangs off it. Texas HSC Chapter 331, 26 TAC §133.55, and PL 2024-10 all require it to be facility-specific, not a generic template; the Joint Commission requires the supporting program elements; and OSHA frames the program around its five components.
VIGILO authors the facility-specific written plan and the supporting policies it cross-references — the confidential reporting and anti-retaliation policy (with explicit law-enforcement non-discouragement language) and the post-incident response protocol (acute treatment offered plus work-assignment adjustment). We format the plan for governing-body adoption and establish the version control surveyors expect.
A purchased template that still carries another facility’s name is one of the most commonly cited Chapter 331 deficiencies. VIGILO rewrites any template into a document that reflects your actual units, risks, and processes, so the tracer holds together. This is a compliance and consulting engagement, not a security-staffing service.
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.
Facility-specific written WVP plan
Every required element, formatted for governing-body adoption.
Reporting & anti-retaliation policy
Confidential, with explicit law-enforcement non-discouragement language.
Post-incident response protocol
Acute treatment offered and work-assignment adjustment.
Version control structure
Revision history and a scheduled-review cadence.
Cross-reference language
Connects the plan to your operational policies so the tracer holds.
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 your written workplace violence prevention plan — is it specific to this facility?
- Who owns the plan, and when was it last reviewed and updated?
- Where in the plan is the committee, the reporting process, the anti-retaliation protection, and the training requirement?
- How do employees report confidentially, and where is your anti-retaliation and law-enforcement non-discouragement language?
- Show me the version history — what changed at the last revision and why?
What surveyors review
- The written plan and supporting policy documents.
- The plan’s review and approval signatures and dates, plus version history.
- Cross-references between the plan and operational policies — reporting, de-escalation, restraint where applicable.
- The confidential reporting policy with confidentiality, anti-retaliation, and law-enforcement non-discouragement language.
- Evidence the plan was adopted by leadership or the governing body and names the leader and committee composition.
Required documentation
| Document | Why surveyors want it |
|---|---|
| Written, facility-specific WVP plan and policy | The statutory spine — must not be a purchased template |
| Confidential reporting + anti-retaliation policy | Must include non-discouragement of contacting law enforcement |
| Post-incident response protocol | Acute treatment offered + work-assignment adjustment (HSC Ch. 331) |
| Adoption / approval record + version control | Leadership signature, date, and revision history |
| Cross-references to operational policies | Connects the plan to floor practice so a tracer cannot break it |
Common deficiencies
- A purchased template with another facility’s name or generic content — fails facility-specificity.
- A plan that exists but was never formally adopted by leadership — no governance, unenforceable program.
- No revision history; the plan is stale, with no evidence of periodic review.
- The plan omits a required element — anti-retaliation, post-incident response, or the annual evaluation.
- The plan contradicts floor practice, or never names the program leader and committee composition.
How to prepare
- Rewrite any template into a facility-specific document — your name, units, risks, and processes.
- Get formal leadership or governing-body adoption with signatures and dates.
- Establish version control and a scheduled review.
- Make sure every required element is explicitly present and findable in the plan.
- Reconcile the plan against actual floor practice so the tracer cannot break it.
How VIGILO helps
VIGILO authors the facility-specific written plan and the supporting policies the plan cross-references — the documentation spine of the binder. We deliver:
- A facility-specific written WVP plan and policy with every required element, formatted for the binder and ready for governing-body adoption.
- A confidential reporting and anti-retaliation policy, with explicit law-enforcement non-discouragement language.
- A post-incident response protocol covering acute treatment offered and work-assignment adjustment.
- Version control and a scheduled-review structure, with regulatory-update memos when a statute or standard changes (through the Annual Compliance Subscription).
- Cross-reference language connecting the plan to your operational policies so the tracer holds together.
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 →Workplace Violence Risk Assessments
A documented environment-of-care worksite analysis, written the way a surveyor reads it.
Flat fee · scoped per engagement
Details →Annual Program Reviews
Your Chapter 331 program of record: annual evaluation, training refresh, and committee support.
Subscription · $1,500–$3,600 / yr per site
Details →Tuned for your facility: Hospitals, Long-Term Care & Nursing Facilities, Home Health & Hospice (HCSSA). See all facilities →
Policy & Plan Development FAQ
Frequently asked questions
What policies does a Chapter 331 workplace violence program require?
At minimum: a written, facility-specific WVP plan; a confidential reporting policy with anti-retaliation protection (including non-discouragement of contacting law enforcement); and a post-incident response protocol providing acute treatment for staff directly involved and work-assignment adjustment. The plan must also name the committee composition and the program’s required elements. VIGILO drafts all of these as a connected, survey-defensible set.
Why is a purchased template a compliance risk?
Because Texas HSC Chapter 331 requires a facility-specific plan, and a generic or purchased template — sometimes still carrying another facility’s name — fails that test and is a commonly cited deficiency. Surveyors also run tracers that break when the written plan contradicts floor practice. VIGILO rewrites any template into a document that reflects your actual units, risks, and processes.
Does the plan need to be adopted by the governing body?
It needs formal adoption to be an enforceable program, and Chapter 331 separately requires the annual plan evaluation to be reported to the governing body. VIGILO formats the plan for governing-body adoption, captures the approval signatures and dates, and establishes the version control surveyors expect to see.
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.