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.
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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 1, 2023, and required covered facilities to adopt and implement a written WVP policy and plan no later than September 1, 2024. That deadline lives in the bill’s uncodified transition section. Cite Acts 2023, 88th Leg., ch. 31, §2, not a Chapter 331 section number, because the codified chapter does not contain it.
In 2025, [SB 463 (89th Legislature)](/texas-sb-240-compliance/sb-463-2026-expansion) amended the facility definition effective September 1, 2025: all HCSSA service categories now count toward the two-RN test, and ICF/IIDs and state supported living centers were added, with a September 1, 2026 compliance deadline for the newly covered.
The statute is enforced in practice through HHSC’s implementing instruments and is checked at the HHSC licensure survey. Each license class has its own: 26 TAC §505.55 for general and special hospitals, §511.79 for limited services rural hospitals, §510.47 for private psychiatric hospitals and crisis stabilization units, §508.31 for ambulatory surgical centers, §509.70 for freestanding emergency medical care facilities, §554.1920 for nursing facilities, and provider-letter guidance for HCSSAs (PL 2024-10) and ICF/IIDs (PL 2026-13) while their proposed rules are pending.
Section 02
Covered facilities
Chapter 331 defines "facility" by reference to existing licensure chapters: eight classes since SB 463 took effect September 1, 2025. Two classes carry a registered-nurse trigger; the threshold sits inside those two definitions and does not reach any other setting.
| General & special hospitals (Ch. 241) | Covered, including hospitals maintained or operated by a state agency. Rule: 26 TAC §505.55 (limited services rural hospitals: §511.79). |
|---|---|
| Mental hospitals (Ch. 577) | Covered. Rule: 26 TAC §510.47. |
| Ambulatory surgical centers (Ch. 243) | Covered: no size threshold. Rule: 26 TAC §508.31. |
| Freestanding emergency medical care facilities (FSEDs) | Covered. Rule: 26 TAC §509.70. |
| Nursing facilities (Ch. 242) | Covered if the facility employs two or more RNs. Rule: 26 TAC §554.1920. |
| HCSSAs: all service categories (Ch. 142) | Covered if the agency employs two or more RNs. SB 463 struck the home-health-only limitation effective Sept. 1, 2025; newly covered categories have been required to comply since Sept. 1, 2026. |
| ICF/IID (Ch. 252) | Covered, added by SB 463; required to comply since Sept. 1, 2026. HHSC guidance: PL 2026-13. |
| State supported living centers (HSC §531.002) | Covered, added by SB 463; required to comply since Sept. 1, 2026. |
| Private physician practices | Excluded. |
| Assisted living facilities (Ch. 247) | Excluded: not in the §331.001 list at any RN staffing level. |
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, always.
- A physician licensed in Texas who provides direct patient care: required. The statute’s only exemption, §331.002(c), reaches an HCSSA that has no such physician on staff; it does not extend to other facility classes by its terms. (For newly covered ICFs, HHSC has addressed physician participation through provider-letter guidance; see PL 2026-13.)
- A facility employee who provides security services: required if any and if practicable. Where the facility employs none, the documentation should say so.
The statute sets a floor ("must include at least"), not a design: it prescribes no committee size, no staff-to-management ratio, and no meeting cadence beyond the annual evaluation. A multi-facility system may operate a single committee under §331.002(d) if the plan is implemented at each facility and violence-prevention data remains distinctly identifiable per facility. A committee missing a required member category is among the easiest deficiencies to cite.
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 an easy finding for a surveyor.
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 workplace violence prevention training or education at least annually. Document it 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 (§331.005). The plan must also adjust patient care assignments, to the extent practicable, so a provider or employee does not have to treat a patient who intentionally physically abused or threatened them (§331.004). 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. A facility can complete the committee’s annual review and still never document that the results reached the governing body, which makes this a Chapter 331 step that is easy to overlook and an easy finding for a surveyor.
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
- May 2023
SB 240 enacted
Senate Bill 240 (88th Texas Legislature) is signed on May 15, 2023, adding Chapter 331 (Workplace Violence Prevention) to the Health & Safety Code.
- Sept. 1, 2023
Statute effective
HSC Chapter 331 takes effect, beginning the runway to the implementation deadline.
- Sept. 1, 2024
First compliance deadline
The originally covered facility classes must have adopted and implemented a written WVP policy and plan: committee, training, reporting policy, and post-incident response in place (uncodified SB 240, §2).
- Sept. 1, 2025
SB 463 expands coverage
SB 463 (89th Legislature, signed May 20, 2025) takes effect: coverage grows from six facility classes to eight. Every HCSSA service category now counts toward the two-RN test, and ICF/IIDs and state supported living centers are added.
- Sept. 1, 2026
Second compliance deadline
Facilities newly covered by SB 463 (non-home-health HCSSAs meeting the two-RN test, ICF/IIDs, and state supported living centers) had to comply with Chapter 331 by this date. Already-covered facilities keep their 2024 obligation.
- 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; amended by SB 463, 89th Legislature, 2025).
- SB 240 enrolled text, 88th Texas Legislature (2023): compliance deadline in uncodified §2.
- SB 463 enrolled text, 89th Texas Legislature (2025): facility-definition amendment; Sept. 1, 2026 transition deadline.
- 26 TAC §505.55: implementing rule for general & special hospitals (adopted Oct. 11, 2024 as 25 TAC §133.55; transferred eff. Jan. 31, 2025).
- Implementing rules for other license classes: 26 TAC §508.31 (ambulatory surgical centers), §509.70 (freestanding emergency medical care facilities), §510.47 (private psychiatric hospitals and crisis stabilization units), §511.79 (limited services rural hospitals), and §554.1920 (nursing facilities).
- HHSC Provider Letter PL 2024-10 (Apr. 18, 2024): HCSSA guidance; predates SB 463 and should be read with the amended statute.
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 with the statutory membership floor; a written, facility-specific policy and plan; at-least-annual employee training; a confidential reporting policy with anti-retaliation protection; post-incident response including acute treatment and patient care assignment adjustment; and an annual plan evaluation reported to the governing body.
Who must be on the Chapter 331 committee?
At least: a registered nurse who provides direct patient care; a physician licensed in Texas who provides direct patient care (an HCSSA with no qualifying physician on staff is exempt from that seat under §331.002(c)); and a facility employee who provides security services, if any and if practicable. A facility may re-authorize an existing committee, and a system may run one committee across facilities if each facility’s data stays distinctly identifiable. The statute sets no committee size, ratio, or meeting cadence beyond the annual evaluation.
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.
Which Chapter 331 requirement is easy to overlook?
The annual plan evaluation reported to the governing body. A facility can complete the committee’s annual review and still 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, and so are assisted living facilities (Chapter 247 is not in the facility list). The eight covered classes are hospitals, mental hospitals, ASCs, FSEDs, ICF/IIDs, and state supported living centers, plus nursing facilities and HCSSAs that employ two or more registered nurses. Excluded facilities may still adopt Joint Commission or OSHA best practice voluntarily.
What does Chapter 331 not require?
The statute prescribes no training curriculum, duration, vendor, or competency test: only that training occur at least annually, and it may be folded into other required training. It sets no committee size, ratio, or meeting cadence beyond the annual evaluation. It requires no incident reporting to HHSC or any state registry. Reporting runs through the facility’s own occurrence systems, and the annual evaluation goes to the facility’s own governing body. And it carries no fine schedule.
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.