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Workplace Violence Prevention Compliance by Healthcare Setting

Texas Health & Safety Code Chapter 331 reaches across the care continuum — general and special hospitals, freestanding emergency departments, ambulatory surgical centers, and mental hospitals are named covered facility classes, while nursing facilities and home health / hospice HCSSAs are covered once they employ two or more registered nurses (the latter through HHSC Provider Letter PL 2024-10). Every covered facility is surveyed on its own. Find your setting below for the obligations, the surveyor questions, and the compliance path tuned to it.

How coverage works

How Chapter 331 decides who is covered

Named covered classes

Hospitals (general and special), freestanding emergency departments, ambulatory surgical centers, and mental hospitals are covered by facility class — coverage does not turn on size or acuity. If you operate one of these, you have been required to maintain a written program since September 1, 2024.

The two-RN threshold

Nursing facilities and home health / hospice HCSSAs are covered once they employ two or more registered nurses — HCSSAs through HHSC Provider Letter PL 2024-10, which defines an employed RN as a current license in a W-2 relationship regardless of duties.

Excluded — but check anyway

Private physician practices are excluded from Chapter 331. But Joint Commission accreditation, payer contracts, OSHA’s General Duty Clause, or a hospital affiliation can still require a program — and a practice operating as a hospital outpatient department may fall under the hospital’s plan.

Coverage FAQ

Frequently asked questions

Which Texas healthcare facilities are covered by Chapter 331?

General and special hospitals, freestanding emergency medical care facilities (FSEDs), ambulatory surgical centers, and mental hospitals are named covered classes. Nursing facilities and home health / hospice HCSSAs are covered once they employ two or more registered nurses (HCSSAs via HHSC Provider Letter PL 2024-10). Private physician practices are excluded.

Is each facility in a health system surveyed separately?

Yes. Coverage and licensure surveys are facility-by-facility, not system-wide. A single system-level committee or one uniform template plan is a structural deficiency surveyors cite — each covered facility needs its own facility-specific program and annual evaluation.

What if my facility class is not on the list?

Coverage can still turn on the two-registered-nurse threshold, a Joint Commission or payer requirement, or a hospital affiliation. A Survey-Readiness Audit confirms your covered-versus-excluded status and documents it.

Not sure whether your facility is covered?

A Survey-Readiness Audit confirms your covered status and scores your committee, plan, training, and governing-body reporting against Chapter 331, the Joint Commission, and OSHA.

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