Workplace Violence Compliance: OSHA & Joint Commission Standards | Vistelar

With regulatory scrutiny of workplace violence prevention intensifying, healthcare organizations face increasing pressure to demonstrate compliance with OSHA and Joint Commission standards. The question is no longer whether your organization will be evaluated on workplace violence prevention, but when, and whether you'll be prepared when that evaluation occurs.

The Evolving Regulatory Landscape

Several key developments have transformed workplace violence prevention from a recommended practice to a mandatory requirement:

• The Joint Commission's workplace violence prevention standards, implemented in January 2022, require healthcare organizations to develop comprehensive violence prevention systems
• OSHA's continued enforcement of the General Duty Clause (Section 5(a)(1) of the Occupational Safety and Health Act), requiring employers to provide workplaces "free from recognized hazards"
• CMS Conditions of Participation, including requirements for addressing workplace violence

State-level Legislation 

States are continuing to mandate workplace violence prevention measures in healthcare settings, enacting laws that specifically addressing workplace violence training for healthcare workers. In 2024, the States of California and North Carolina implemented new legislation outlining specific requirements for de-escalation training for healthcare workers. In 2025,  Ohio began requiring de-escalation training for healthcare security personnel, emergency department staff, and psychiatric workers. Both Oregon and Virginia followed suit by introducing similar legislation.  

These overlapping requirements create complex compliance challenges that demand systematic approaches to workplace violence prevention.

Key Compliance Requirements

While specific requirements vary somewhat, several common elements emerge that all healthcare organizations must address:

1.   Comprehensive Risk Assessment

Both OSHA and The Joint Commission require organizations to conduct thorough risk assessments that identify potential violence hazards. These assessments must include:

• Analysis of physical environment vulnerabilities
• Review of administrative and work practice controls
• Evaluation of past incidents and near-misses
• Assessment of staffing and security arrangements
• Identification of high-risk areas and situations

2.    Written Violence Prevention Plan 

Organizations must develop and maintain a written workplace violence prevention plan that includes:

• Clear policies prohibiting workplace violence
• Specific procedures for preventing and responding to violence
• Defined responsibilities for implementation and oversight
• Process for periodic review and update
• Integration with broader emergency management planning

3.    Staff Training 

All regulatory frameworks require staff training on workplace violence prevention, though specific requirements vary. At a minimum, training must include:

• Recognition of warning signs for potential violence
• De-escalation techniques for managing aggressive behavior
• Reporting procedures for workplace violence incidents
• Response protocols when violence occurs
• Regular refresher training to maintain skills

4.    Incident Reporting and Analysis 

Organizations must implement robust systems for reporting and analyzing workplace violence incidents, including:

• Clear procedures for reporting incidents and near-misses
• Tracking mechanisms to identify patterns and trends
• Regular analysis of data to identify improvement opportunities
• Documentation of corrective actions taken
• Protection for staff who report incidents from retaliation

5.    Post-Incident Response

Effective post-incident response includes:

• Medical evaluation and treatment for affected staff
• Psychological support services
• Debriefing procedures to identify lessons learned
• Implementation of corrective actions
• Documentation of the entire process

Preparing for Regulatory Scrutiny 

To ensure audit readiness, healthcare organizations should take these specific steps:

1.   Conduct a Gap Analysis

Compare your current workplace violence prevention program against regulatory requirements to identify areas needing improvement. This analysis should examine:

• Existing policies and procedures
• Training programs and participation rates
• Environmental safety measures
• Incident reporting systems
• Post-incident response protocols

2.   Implement Comprehensive Training

Vistelar's Unified Conflict Management System provides a systematic approach to workplace violence prevention that addresses the entire spectrum of human conflict. This comprehensive training includes:

• Non-escalation tactics to prevent conflict before it begins
• De-escalation techniques for managing situations showing signs of escalation
• Crisis intervention methods for situations where individuals are unable to cope
• Appropriate response when physical intervention becomes necessary
• Recovery procedures to restore safety after incidents 

This systematic approach not only satisfies regulatory requirements but creates lasting behavioral change that transforms organizational culture.

3.    Provide Comprehensive Documentation  

Regulatory compliance requires thorough documentation of all workplace violence prevention efforts, including:

• Risk assessment findings and mitigation actions
• Training records showing who received training and when
• Incident reports and investigation results
• Committee meeting minutes related to workplace safety
• Evidence of continuous improvement efforts

4.    Conduct Regular Self-Assessments 

Don't wait for regulatory surveys to identify compliance gaps. Schedule regular self-assessments using tools aligned with regulatory requirements, such as:

• The Joint Commission's workplace violence prevention standards
• OSHA's Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers
• CMS Emergency Preparedness Rule components related to workplace violence

Beyond Compliance: Creating a Culture of Safety

The most effective approach to meeting regulatory requirements is implementing systems that transform workplace culture rather than merely checking regulatory boxes. When staff at all levels internalize effective conflict management principles, the organization naturally aligns with regulatory expectations while creating a fundamentally safer environment.

By implementing comprehensive systems that address the entire spectrum of workplace violence—from prevention through response—you position your organization for successful regulatory surveys while protecting your most valuable asset: your people.