Who we serve · Hospitals
Workplace Violence Prevention for Texas Hospitals
Under Texas Health & Safety Code Chapter 331 and its implementing rule 26 TAC §505.55 (adopted October 2024), general and special hospitals have been required since September 1, 2024 to maintain a written workplace violence prevention program, and if you are Joint Commission-accredited, you carry a parallel set of expectations under National Performance Goal #2a (NPG.02.04.01; introduced January 1, 2022 in the EC, HR, and LD chapters).
Hospitals face the highest scrutiny: your emergency department and behavioral-health units concentrate risk, your survey footprint is large, and after an incident your written program becomes the first item in discovery. VIGILO builds the hospital program that holds up under both a survey and a deposition.
Where the mandate applies
How Chapter 331 reaches your setting
- General and special hospitals (HSC Chapter 241) are a covered facility class under HSC Chapter 331, enforced through 26 TAC §505.55 (adopted October 2024).
- Required since September 1, 2024; compliance is checked at the licensure survey, and Joint Commission-accredited hospitals carry parallel requirements under National Performance Goal #2a (NPG.02.04.01; introduced January 1, 2022 in the EC, HR, and LD chapters).
- The committee must include a registered nurse providing direct patient care, a physician licensed in Texas providing direct patient care (employed, contracted, or independent), and a security-services employee if any and if practicable.
- Required elements: committee, facility-specific written plan, at-least-annual training, confidential anti-retaliation reporting, post-incident response, and an annual plan evaluation reported to the governing body.
- Chapter 331 has no fine schedule; enforcement is a licensure-survey deficiency plus post-incident litigation discovery. The annual governing-body report is a step that is easy to overlook.
Speaking the language of surveyors
The six-part surveyor framework, 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
- Is your WVP committee properly composed, including a registered nurse providing direct patient care, a physician licensed in Texas providing direct care (required whether employed, contracted, or independent), and a security-services employee, if any and if practicable?
- Does your written plan address high-risk hospital areas: ED, behavioral health, ICU, L&D, and after-hours access?
- Is training delivered annually and at orientation across a large, multi-shift workforce?
- Did your committee complete an annual plan evaluation reported to the governing body?
- Can you show incident tracking and trending at the volume a hospital generates?
What surveyors review
- Committee charter, membership roster (confirming required clinical and security roles), and minutes.
- The facility-specific written WVP plan with unit-level risk treatment.
- Training rosters across departments and shifts.
- Incident logs with tracking, trending, and analysis.
- The annual evaluation report and its presentation to the governing body.
Required documentation
| Document | Why surveyors want it |
|---|---|
| WVP committee charter + membership | Must reflect RN-direct-care, physician-direct-care, and (if any and if practicable) security-services roles |
| Facility-specific written plan | Unit-level treatment for ED, behavioral health, high-acuity areas |
| Annual + orientation training records | Across all departments and shifts |
| Incident reporting/tracking/trending dataset | Volume and analysis a hospital is expected to produce |
| Annual plan evaluation to governing body | The statutory recurring obligation |
Common deficiencies
- An incomplete committee: missing the required physician or security-services member.
- A plan that reads generic and does not address the ED and behavioral-health risk that defines hospital exposure.
- Training that covers day-shift staff but misses nights, weekends, and contract clinicians.
- Incident data collected but never trended, so leadership cannot show analysis.
- No documented annual report to the governing body: a statutory step that is easy to overlook.
How to prepare
- Audit your committee composition first: a non-compliant committee invalidates everything downstream.
- Make the plan unit-specific for your highest-risk areas.
- Build a shift-spanning training plan so no population is missed.
- Stand up incident trending your committee reviews quarterly.
- Calendar the annual governing-body report and keep the presentation in the binder.
How VIGILO helps
VIGILO delivers the complete hospital program through the WVP Foundation Package and keeps it current through the Annual Compliance Subscription:
- A compliant committee charter with appointment letters confirming the required RN, physician, and security-services roles, plus first-meeting facilitation and minutes.
- A facility-specific written plan with unit-level risk treatment for ED, behavioral health, and high-acuity areas.
- Annual and orientation training, English and Spanish, across departments and shifts.
- An incident reporting, tracking, and trending structure sized for hospital volume.
- The annual plan evaluation prepared for, and documented to, your governing body, every year.
Texas SB 240 compliance
See the full statute breakdown, the covered-facilities matrix, and the implementing rules on our Texas SB 240 compliance hub.
Recommended path
Audit → Foundation → Annual program of record
Survey-Readiness Audit
A scored gap report against Chapter 331, the HHSC rule for your license class, and the Joint Commission requirements.
Flat fee · $500 to $1,500
Details →Workplace Violence Prevention Programs
The complete, facility-specific program of record: committee, plan, training, and binder.
Flat fee · $2,500 to $6,000
Details →Annual Program Reviews
Your Chapter 331 program of record: annual evaluation, training refresh, and committee support.
Subscription · $1,500 to $3,600 / yr per site
Details →Serving every covered healthcare facility class across Texas. See all settings we serve →
Hospitals compliance FAQ
Frequently asked questions
Are Texas hospitals required to have a workplace violence prevention program?
Yes. Under Texas Health & Safety Code Chapter 331 and its implementing rule 26 TAC §505.55 (adopted October 2024), general and special hospitals have been required since September 1, 2024 to maintain a written, facility-specific workplace violence prevention program, including a committee, a plan, at-least-annual training, a confidential anti-retaliation reporting policy, post-incident response, and an annual plan evaluation reported to the governing body.
Who must serve on a hospital WVP committee under Chapter 331?
The committee must include a registered nurse who provides direct patient care; a physician licensed in Texas who provides direct patient care, whether employed, contracted, or independent; and a security-services employee if the hospital employs any and if practicable. An incomplete committee is a deficiency a surveyor can cite straight from the roster.
Do Joint Commission workplace violence requirements also apply to hospitals?
If a hospital is Joint Commission-accredited, yes. TJC’s workplace violence prevention requirements (effective January 1, 2022 for hospitals; now National Performance Goal #2a) were introduced across the Environment of Care, Human Resources, and Leadership chapters and require a designated program leader, an annual worksite analysis, incident reporting/tracking/trending, post-incident strategies, and training at orientation, annually, and when the program changes. VIGILO builds one program that satisfies both Texas Chapter 331 and the Joint Commission.
Which Chapter 331 step is easy for a hospital 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 obligation that surveyors check and that becomes evidence in post-incident litigation discovery.
Would your hospital program hold up under survey?
A Survey-Readiness Audit scores your committee, plan, training, and governing-body reporting against Chapter 331, the Joint Commission, and OSHA, in one document.