Texas SB 240 · Primary source
HSC Chapter 331 Requirements: Texas Workplace Violence Prevention
Texas Health & Safety Code Chapter 331 requires covered healthcare facilities to maintain a written, facility-specific workplace violence prevention program. It mandates a WVP committee with specified members, a facility-specific 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.
On this page
Section 01
Where Chapter 331 comes from
Chapter 331 was added to the Texas Health & Safety Code by Senate Bill 240, 88th Legislature (2023). The statute took effect September 15, 2023, and required covered facilities to adopt and implement a written WVP policy and plan no later than September 1, 2024.
The statute is enforced in practice through HHSC’s implementing instruments — 26 TAC §133.55 for general and special hospitals, and Provider Letter PL 2024-10 (Revised) for home health and hospice — and is checked at the HHSC licensure survey.
Section 02
Covered facilities
Chapter 331 defines "facility" by reference to existing licensure chapters. Two classes carry a registered-nurse trigger.
| General & special hospitals (Ch. 241) | Covered. |
|---|---|
| Mental hospitals (Ch. 577) | Covered. |
| Ambulatory surgical centers (Ch. 243) | Covered. |
| Freestanding emergency medical care facilities (FSEDs) | Covered. |
| Nursing facilities (Ch. 242) | Covered if the facility employs two or more RNs. |
| HCSSAs / home health & hospice (Ch. 142) | Covered if the agency employs two or more RNs (PL 2024-10). |
| Private physician practices | Excluded. |
Section 03
Requirement 1 — The WVP committee
Chapter 331 requires a workplace violence prevention committee with specified membership. A facility may re-authorize an existing committee rather than create a new one, but the required member categories must be present.
- A registered nurse who provides direct patient care — required.
- A physician who provides direct patient care, if the facility employs any physicians.
- A security-services employee, if the facility employs any.
A committee missing a required member category is among the most commonly cited deficiencies. The RN-providing-direct-care seat and the physician seat are the ones most often overlooked.
Section 04
Requirement 2 — The written, facility-specific plan
The facility must adopt a written workplace violence prevention policy and plan that is specific to the facility — its units, its emergency department and behavioral-health exposure, its security posture, and its own incident history. A purchased template carrying another facility’s name or generic content fails the facility-specific test and is a routine citation.
The plan is the spine of the survey binder: the committee, training, reporting, post-incident response, and annual evaluation all hang off it. See policy development for how the plan and its supporting policies are built.
Section 05
Requirement 3 — Training at least annually
Chapter 331 requires employee training and education at least annually, documented with completion records for all applicable staff. Surveyors reconcile training rosters against the employee census — and specifically check contracted, agency, and per-diem staff, who are a frequent gap.
VIGILO delivers healthcare staff training and de-escalation training, in English and Spanish, tied to the statutory annual cadence and documented for the binder.
Section 06
Requirement 4 — Confidential reporting with anti-retaliation protection
The facility must maintain a confidential reporting policy with anti-retaliation protection. It cannot discipline, discriminate, or retaliate against an employee who in good faith reports a workplace violence incident, and it cannot discourage employees from contacting law enforcement.
A reporting policy that omits explicit anti-retaliation or law-enforcement non-discouragement language is cited because it violates a specific statutory prohibition, not just best practice.
Section 07
Requirement 5 — Post-incident response
After an incident, the facility must offer immediate post-incident services, including any necessary acute medical treatment, to staff directly involved, and adjust work assignments as appropriate. This is the requirement with the sharpest post-incident litigation exposure: after a serious assault, discovery asks whether the facility actually offered and documented this support.
Section 08
Requirement 6 — Annual plan evaluation reported to the governing body
The committee must meet at least annually to evaluate the plan and report the results to the facility’s governing body. The board-reporting step is a distinct statutory obligation — many facilities complete the committee’s annual review but never document that the results reached the governing body, which is the single most overlooked Chapter 331 step and a routine survey finding.
This element is what makes Chapter 331 a renewing, annual obligation. VIGILO carries it through annual program reviews.
Section 09
Enforcement and the honest take on penalties
Chapter 331 has no dedicated fine schedule. Non-compliance is enforced as a licensure-survey deficiency — requiring a plan of correction, with possible disciplinary action against the facility’s license — and surfaces in post-incident litigation discovery. Frame the urgency on survey-readiness and litigation exposure, accurately. There is no statutory fine to cite, and we never imply one.
Key dates
Dates that matter
- June 2023
SB 240 enacted
The 88th Texas Legislature passes Senate Bill 240, adding Chapter 331 (Workplace Violence Prevention) to the Health & Safety Code.
- Sept. 15, 2023
Statute effective
HSC Chapter 331 takes effect, beginning the runway to the implementation deadline.
- Sept. 1, 2024
Compliance deadline
Covered facilities must have adopted and implemented a written WVP policy and plan — committee, training, reporting policy, and post-incident response in place.
- Annually, thereafter
Recurring obligation
The committee must evaluate the plan at least annually and report the results to the governing body — a renewing statutory duty, not a one-time project.
Primary sources
- Texas Health & Safety Code Chapter 331 — Workplace Violence Prevention (added by SB 240, 88th Legislature, 2023).
- SB 240 enrolled text, 88th Texas Legislature (2023).
- 26 TAC §133.55 — implementing rule for general & special hospitals (adopted Oct. 11, 2024).
- HHSC Provider Letter PL 2024-10 (Revised) — application to home health and hospice HCSSAs.
Part of the Texas SB 240 compliance hub.
Frequently asked
Frequently asked questions
What does HSC Chapter 331 require?
Chapter 331 requires covered Texas healthcare facilities to maintain six things: a workplace violence prevention committee (including a registered nurse who provides direct care, a physician providing direct care if employed, and a security-services employee if employed); a written, facility-specific plan; at-least-annual employee training; a confidential reporting policy with anti-retaliation protection; post-incident response including acute treatment and work-assignment adjustment; and an annual plan evaluation reported to the governing body.
Who must be on the Chapter 331 committee?
The committee must include a registered nurse who provides direct patient care; a physician who provides direct patient care if the facility employs any physicians; and a security-services employee if the facility employs any. A facility may re-authorize an existing committee. Missing a required member category — most often the RN providing direct care or the physician — is a common cited deficiency.
How often is training required under Chapter 331?
At least annually, for all applicable employees, documented with completion records. Surveyors reconcile training rosters against the full employee census and specifically check contracted, agency, and per-diem staff, who are a frequent gap. Joint Commission-accredited facilities also train at orientation and when the program changes.
What is the most overlooked Chapter 331 requirement?
The annual plan evaluation reported to the governing body. Facilities frequently complete the committee’s annual review but never document that the results were reported to the board — a distinct statutory step that surveyors check and that becomes evidence in post-incident litigation discovery.
Are private physician practices covered by Chapter 331?
No. Private physician practices are excluded from Chapter 331. Covered classes are hospitals, mental hospitals, ASCs, and FSEDs, plus nursing facilities and home health/hospice agencies that employ two or more registered nurses. Excluded facilities may still adopt Joint Commission or OSHA best practice voluntarily.
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.