Texas SB 240 · Primary source
26 TAC §505.55: The Texas Hospital Workplace Violence Prevention Rule
26 TAC §505.55 is the HHSC administrative rule, adopted in the Texas Register on October 11, 2024, that implements HSC Chapter 331 for general and special hospitals. It requires each hospital to establish or authorize a workplace violence prevention committee and to adopt, implement, and enforce a written, facility-specific WVP policy and plan — checked at the hospital licensure survey.
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Section 01
What 26 TAC §505.55 is
26 TAC §505.55 sits in the Texas Administrative Code chapter governing hospital licensing (Title 26, Chapter 505, Subchapter C — Operational Requirements). It is the rule that turns HSC Chapter 331’s statutory requirements into a licensure condition for general and special hospitals — the mechanism by which an HHSC surveyor can write a hospital up for a workplace violence prevention gap.
Citation hygiene matters here, because the rule has moved. It was adopted as 25 TAC §133.55, published in the Texas Register on October 11, 2024 (Vol. 49, No. 41) and effective October 21, 2024. When HHSC transferred the hospital licensing chapter into Title 26, the rule became 26 TAC §505.55, effective January 31, 2025. So "25 TAC §133.55" was correct for roughly fourteen weeks and is now stale; "26 TAC §133.55" was never a real citation; 26 TAC §505.55 is correct today. The rule does not change the underlying obligations of Chapter 331; it operationalizes them inside the hospital survey process.
One requirement in the rule goes beyond the statute: each hospital "shall make available on request an electronic or printed copy of the hospital’s workplace violence prevention plan to each health care provider or employee." A hospital can satisfy Chapter 331 and still be cited under §505.55 on this point alone — build plan-availability into your policy.
Section 02
What the rule requires of hospitals
Tracking Chapter 331, 26 TAC §505.55 requires each covered hospital to:
- Establish or authorize a WVP committee with the required membership — a registered nurse providing direct patient care; a physician licensed in Texas providing direct patient care (required for hospitals — the statute’s narrow physician exemption reaches only HCSSAs); and a security-services employee if the hospital employs any and if practicable.
- Adopt, implement, and enforce a written, facility-specific WVP policy and plan addressing the hospital’s own high-risk areas.
- Provide employee training at least annually.
- Maintain a confidential reporting policy with anti-retaliation protection, including non-discouragement of contacting law enforcement.
- Provide post-incident response — acute medical treatment for staff directly involved and work-assignment adjustment.
- Conduct an annual plan evaluation and report the results to the governing body.
Section 03
How surveyors check it
An HHSC licensing surveyor checks §505.55 during the hospital licensure or re-licensure survey, alongside the rest of the licensing conditions, using tracer methodology — pulling the thread from policy to plan to committee to training record to corrective action.
| Written, facility-specific plan | Surveyor confirms it is specific to this hospital, with an adoption date on or before Sept. 1, 2024 (or the licensure date if later). |
|---|---|
| Committee charter + roster | Verifies the RN-providing-direct-care, physician-providing-direct-care, and security-services member categories. |
| Committee meeting minutes | Reviews the trailing 12 months, including the annual plan evaluation. |
| Governing-body report | Looks for board minutes or a signed report showing the annual evaluation reached the governing body. |
| Reporting / anti-retaliation policy | Checks for explicit anti-retaliation and law-enforcement non-discouragement language. |
| Annual training roster | Reconciles against the full employee and contracted-staff census. |
| Post-incident response records | Confirms treatment offered and assignment adjusted for sampled incidents. |
Section 04
Common deficiencies under §505.55
- A generic template plan rather than a facility-specific one naming the hospital’s ED, behavioral-health units, and high-acuity areas.
- A committee missing a required member — most often the physician providing direct care or the security-services employee.
- An annual evaluation completed but never reported to the governing body.
- Training that covers day-shift staff but misses nights, weekends, and contracted clinicians.
- A reporting policy lacking anti-retaliation or law-enforcement language.
- Incident data collected but never trended to a level leadership can show analysis.
Section 05
How §505.55 interacts with the Joint Commission
If a hospital is Joint Commission-accredited, it carries a parallel set of WVP requirements — since January 1, 2026 scored at NPG.02.04.01 (Elements of Performance 1–3, under National Performance Goal #2a), with incident monitoring at NPG.11.01.01 EP 3. The substance carried over from the 2022 EC/HR/LD requirements: a designated program leader and multidisciplinary team, an annual worksite analysis with action on findings, incident reporting/tracking/trending, post-incident support including trauma and psychological counseling where necessary, reporting of incidents to the governing body, and training at hire, annually, and on program change.
The obligations overlap heavily. VIGILO builds one hospital program that satisfies both 26 TAC §505.55 and the Joint Commission, and rehearses it through mock surveys and Joint Commission readiness.
Limited services rural hospitals carry their own dedicated rule, 26 TAC §511.79, effective October 9, 2025. §505.55 is a hospital licensing rule only — no parallel HHSC WVP rule exists for ASCs, FSEDs, nursing facilities, HCSSAs, ICF/IIDs, or state supported living centers; those classes are governed by the statute plus provider-letter guidance.
Key dates
Dates that matter
- Jan. 1, 2022
Joint Commission requirements
TJC workplace violence prevention requirements take effect for accredited hospitals (then in the EC/HR/LD chapters).
- Sept. 1, 2024
Compliance deadline
Covered hospitals must have adopted and implemented a written WVP policy and plan.
- Oct. 21, 2024
Rule effective (as 25 TAC §133.55)
Adopted and published in the Texas Register Oct. 11, 2024 (Vol. 49, No. 41); effective ten days later.
- Jan. 31, 2025
Renumbered to 26 TAC §505.55
The hospital licensing chapter transfers into Title 26; §133.55 becomes §505.55. Use the Title 26 citation from this date forward.
- Jan. 1, 2026
TJC citation moves to NPG.02.04.01
Under Accreditation 360, the hospital WPV requirements are scored at NPG.02.04.01 (National Performance Goal #2a); the EC/HR/LD numbering is retired for hospitals.
- Annually
Annual evaluation
The committee evaluates the plan and reports the results to the governing body each year.
Primary sources
- 26 TAC §505.55 — Workplace Violence Prevention (general & special hospitals); adopted as 25 TAC §133.55, Texas Register Oct. 11, 2024 (Vol. 49, No. 41); transferred to Title 26 eff. Jan. 31, 2025.
- 26 TAC §511.79 — Workplace Violence Prevention (limited services rural hospitals); effective Oct. 9, 2025.
- Texas Health & Safety Code Chapter 331 (added by SB 240, 88th Legislature, 2023; amended by SB 463, 89th Legislature, 2025).
- Texas Secretary of State — HHSC rule transfer notice (25 TAC Ch. 133 → 26 TAC Ch. 505), effective Jan. 31, 2025.
- The Joint Commission — NPG.02.04.01, Workplace Violence Prevention (National Performance Goal #2a), effective Jan. 1, 2026 for hospitals; previously EC/HR/LD chapters from Jan. 1, 2022.
Part of the Texas SB 240 compliance hub.
Frequently asked
Frequently asked questions
What is 26 TAC §505.55?
26 TAC §505.55 is the Texas HHSC administrative rule, adopted in the Texas Register on October 11, 2024, that implements HSC Chapter 331 for general and special hospitals. It requires each hospital to establish or authorize a workplace violence prevention committee and to adopt, implement, and enforce a written, facility-specific WVP policy and plan, and it is checked at the hospital licensure survey.
When was 26 TAC §505.55 adopted?
The rule was adopted and published in the Texas Register on October 11, 2024 (Volume 49, Number 41). It implements HSC Chapter 331 for hospitals; the underlying statutory compliance deadline for covered facilities was September 1, 2024.
How do surveyors check 26 TAC §505.55?
An HHSC licensing surveyor checks the rule at the hospital licensure or re-licensure survey using tracer methodology. They review the facility-specific written plan, the committee charter and roster, committee minutes including the annual evaluation, the governing-body report, the anti-retaliation reporting policy, annual training rosters reconciled against the census, and post-incident response records.
Does 26 TAC §505.55 apply to all Texas hospitals?
It applies to general and special hospitals licensed under HSC Chapter 241. Limited services rural hospitals have their own dedicated rule, 26 TAC §511.79, effective October 9, 2025. It does not apply to ASCs, FSEDs, nursing facilities, HCSSAs, ICF/IIDs, or state supported living centers — citing §505.55 to those settings is a scope error; they are governed by the statute plus provider-letter guidance. Joint Commission-accredited hospitals also carry parallel WVP requirements, scored since January 1, 2026 at NPG.02.04.01 (National Performance Goal #2a).
What is the most common §505.55 deficiency?
A generic, non-facility-specific plan and an annual evaluation that was completed but never reported to the governing body. An incomplete committee — missing the physician providing direct care or the security-services member — and training gaps among night, weekend, and contracted staff are also frequently cited.
Find out where your program stands
A Survey-Readiness Audit scores your committee, plan, training, reporting policy, and governing-body evaluation against every applicable Chapter 331 instrument — in one document.