Build · The program of record
Workplace Violence Prevention Programs for Healthcare Facilities
Texas Health & Safety Code Chapter 331 (created by SB 240, 88th Legislature, 2023) requires every covered healthcare facility to maintain a written, facility-specific workplace violence prevention program — and to keep it current with an annual evaluation reported to the governing body. The mandate is not a class or a binder you assemble once; it is a program of record a surveyor opens and your governing body signs off on.
Most facilities have pieces — a policy here, a training session there. Few have a binder that holds together under a licensure survey or, after an incident, in litigation discovery. VIGILO builds the complete program: the committee, the facility-specific written plan, the reporting and anti-retaliation policy, the initial all-staff training, and the assembled survey-readiness binder.
This is a compliance, training, and consulting engagement. VIGILO does not provide security guard, patrol, or investigative services, and does not guarantee safety outcomes. Chapter 331 carries no dedicated fine schedule — the exposure is a survey deficiency and post-incident litigation discovery, which is exactly why under-preparing is easy.
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 the binder and governing-body adoption.
Committee charter + appointment letters
Confirms the RN, physician, and security-services roles, with first-meeting facilitation and minutes.
Reporting & anti-retaliation policy
Confidential, with explicit law-enforcement non-discouragement language.
Initial all-staff training
English and Spanish, with completion records for the survey file.
Survey-readiness binder
Plan, charter, minutes, policy, and training records, assembled in one file.
Annual maintenance option
Kept current year after year through the Annual Compliance Subscription.
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, facility-specific workplace violence prevention plan — when was it adopted, and who owns it?
- Who is on your WVP committee? Show me an RN providing direct patient care is a member — and a physician and a security-services employee, if you employ any.
- Walk me through how the plan covers prevention, reporting, training, post-incident response, and the annual evaluation.
- Show me the committee minutes and the annual plan evaluation reported to your governing body in the last 12 months.
- Does the plan match what actually happens on the floor — can a frontline nurse describe how to report an incident?
What surveyors review
- The written WVP policy and plan — confirming it is facility-specific, not a purchased template with another facility’s content.
- The committee charter, appointment letters, and membership roster verifying every required member category.
- Committee meeting minutes for the trailing twelve months, including the annual plan evaluation.
- Governing-body minutes or a signed report proving the annual evaluation reached the board.
- The confidential reporting and anti-retaliation policy, the annual training roster, and post-incident response records.
Required documentation
| Document | Why surveyors want it |
|---|---|
| Written, facility-specific WVP policy and plan | The statutory spine — every other artifact hangs off it (HSC Ch. 331) |
| Committee charter + appointment letters + roster | Documents the RN-direct-care, physician-direct-care, and security-services member categories |
| Committee meeting minutes (trailing 12 months) | Without minutes the program is unprovable at survey |
| Annual plan evaluation + governing-body report | The single most overlooked Ch. 331 obligation |
| Confidential reporting + anti-retaliation policy | Must include non-discouragement of contacting law enforcement |
| Annual training roster + post-incident response records | Closes the program loop a surveyor traces |
Common deficiencies
- A generic or purchased plan that is not facility-specific — the most common Chapter 331 citation.
- A committee missing a required member category, most often the RN providing direct patient care.
- A plan that exists but was never formally adopted by leadership or the governing body.
- The annual evaluation completed but never reported to the governing body — a distinct statutory step surveyors check.
- A reporting policy that omits anti-retaliation or law-enforcement non-discouragement language.
How to prepare
- Confirm coverage first — facility class, plus the two-or-more-RN trigger for nursing facilities and HCSSAs.
- Make the plan demonstrably facility-specific: name your units, your ED, your security posture, your local risks.
- Build the committee with the exact required member categories and document the appointments in writing.
- Put the annual plan evaluation on the calendar and make the governing-body report a permanent agenda item with a paper trail.
- Assemble the plan, charter, minutes, policy, and training records into a single survey-readiness binder.
How VIGILO helps
VIGILO delivers the complete program of record through the WVP Foundation Package — the documented, facility-specific program a surveyor opens and a governing body signs off on:
- A facility-specific written WVP policy and plan with every required element, formatted for the binder and ready for governing-body adoption.
- A committee charter and appointment letters confirming the required RN, physician, and security-services roles, plus first-meeting facilitation and minutes.
- The confidential reporting and anti-retaliation policy, with explicit law-enforcement non-discouragement language.
- Initial all-staff training — English and Spanish — with completion records for the survey file.
- An assembled survey-readiness binder, kept current year after year through the Annual Compliance Subscription.
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.
Survey-Readiness Audit
A scored gap report against the Chapter 331 / 26 TAC §133.55 / PL 2024-10 / Joint Commission checklist.
Flat fee · $500–$1,500
Details →Policy & Plan Development
The facility-specific written plan plus reporting, anti-retaliation, and post-incident policies.
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 →
Workplace Violence Prevention Programs FAQ
Frequently asked questions
What is a workplace violence prevention program under Texas Chapter 331?
It is a written, facility-specific program every covered Texas healthcare facility has been required to maintain since September 1, 2024 under Health & Safety Code Chapter 331 (created by SB 240, 88th Legislature, 2023). It has six parts: a WVP committee, a written plan, at-least-annual employee training, a confidential anti-retaliation reporting policy, post-incident response, and an annual plan evaluation reported to the governing body. VIGILO builds all six as one survey-defensible program of record.
Who must serve on the WVP committee?
Chapter 331 requires a registered nurse who provides direct patient care; a physician who provides direct patient care if the facility employs any; and a security-services employee if the facility employs any. An incomplete committee — most often missing the RN providing direct care or the security-services member — is a frequently cited deficiency.
Is there a fine for not having a program?
Chapter 331 carries no dedicated fine schedule. Exposure surfaces instead as a deficiency at your licensure survey, possible disciplinary action against the license, and through discovery in post-incident litigation, where your written plan, committee minutes, and training records become evidence. The practical risk is survey-readiness and litigation exposure, not a fixed penalty.
Does one program satisfy the Joint Commission and OSHA too?
Yes — that is the point of building it once. A well-constructed Chapter 331 program maps to the Joint Commission EC/HR/LD workplace violence requirements (effective January 1, 2022 for hospitals) and to OSHA’s five-component framework under Publication 3148 and the General Duty Clause §5(a)(1). VIGILO builds one binder that answers all three regimes.
Is VIGILO a security-guard, patrol, or investigations service?
No. VIGILO is a healthcare compliance, training, and consulting firm. We build and maintain survey-defensible workplace violence prevention programs and documentation; we do not provide security guard, patrol, armed, or investigative services, and we do not guarantee safety outcomes. Where we reference "security," it is in a compliance context — an environment-of-care security risk assessment, or the security-services employee a Chapter 331 committee must include if the facility employs any.
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.