|Origination||03/2019||Owner||Lawrence Jordan III: NLCS General Counsel and CCO|
|Last Approved||02/2021||Policy Area||Compliance|
Our Compliance and Ethics Program Code of Conduct covers the compliance issues, laws and
regulations, and guidelines that are relevant to a provider of senior services including Senior Living
Communities that provide a wide range of healthcare services. This includes but is not limited to
Medicare and Medicaid regulatory issues; guidelines from the Office of Inspector General, Internal
Revenue Service, and the Office of Civil Rights of the Department of Health and Human Services,
Occupational Safety and Health Administration; as well as other federal and state regulatory and
business issues. The program fosters a culture of compliance that promotes legal and ethical behavior
in the workplace by creating processes that detect and prevent fraud, waste, abuse, and policy violations.
The Code of Conduct is supported by our compliance policies and procedures and should be read and
understood jointly with those policies and procedures.
We use the term team member to define the various individuals who are associated with National
Lutheran Communities & Services (NLCS). All individuals, including employees, contractors, volunteers,
directors, and officers are members of our team in providing care and services to our residents. We use
the term Resident to refer to individuals who receive the various types of healthcare and other services
that we provide.
Any questions regarding the policies in this Code of Conduct, compliance policies, or related references,
should be directed to your immediate supervisor, the Compliance Officer, or a member of the Compliance
National Lutheran Communities & Services is a faith-based organization providing services to seniors in
a variety of settings. NLCS is licensed under the laws of Maryland and/or Virginia to provide the
Lawrence Jordan III, General Counsel, serves as our Compliance Officer. He has the responsibility to
assist the High-Level Official and the Board of Directors/Trustees in designing and overseeing efforts in
establishing, maintaining, and monitoring compliance within our organization.
The Compliance Officer works with each of our Executive Directors and has direct reporting
responsibility to the Board of Directors. The Compliance Officer is responsible for the development,
implementation, training, monitoring, and enforcement activities related to the overall compliance
program. The Compliance Officer is assisted by Peace Church Compliance Program (PCCP) Compliance
Managers and Compliance Specialists in providing services to our organization.
Our Board of Directors/Trustees, through the President and Chief Executive Officer (CEO) Larry
Bradshaw, carries the overall responsibility for creating a culture that values and emphasizes compliance
The Compliance Officer is responsible for coordinating the day-to-day compliance activities. These
activities include audits, responses to hotline calls, and leading the organization’s Compliance
Committee. The high-level official sets the tone for a community wide commitment to compliance and is
accountable to assure that the compliance program and adherence to the Compliance and Ethics
Program is attained. The Privacy Officer and is responsible for assisting with the implementation of the
HIPAA Privacy Rule. The Security Officer and is responsible for assisting with the implementation of the
HIPAA Security Rule and issues related to electronic protected health information. A list of the current
officials and officers is located in the conclusion.
The NLCS’ Compliance Committee is comprised of members of the management team and other key
staff positions. The Compliance Officer is the chairperson for this committee. The committee meets at
least quarterly, and more frequently as needed.
January 1, 2019
Dear Team Members:
National Lutheran Communities & Services (NLCS) has more than 125 years of tradition in providing
home and healthcare services to senior adults with compassion, respect and dignity of each resident and team member. We strive to follow the organization’s Lutheran heritage of ethical and moral decision-
making for all who live and work here.
The healthcare industry is constantly changing and being impacted by numerous laws and regulations.
In our desire to establish a work place that complies with these laws and regulations, we have developed
a Compliance and Ethics Program that supports NLCS, its affiliates and team members in making the
right decisions. This document, called the Code of Conduct, represents the primary focus for our Compliance and Ethics Program. The Code of Conduct not only reflects our heritage and values, but also
serves as a bold statement that influences how we enhance a resident’s quality of life.
The Compliance and Ethics Program and the Code of Conduct only exist to guide our normal decisions
that are both ethical and compliant with applicable laws, statutes and regulations. Our Code of Conduct
does not replace each person’s obligation of making wise, fair and honest decisions. It is intended to
explain our personal and organizational responsibility and to reflect those areas in which improper or
unwise decisions can harm our entire organization and our commitment to share Christian love and
compassion to those we serve.
We value your contribution to our residents and appreciate your support in properly maintaining the most
ethical work place possible. We commend you for your commitment of honesty and integrity, which are
also part of our values at NLCS. Each team member is responsible in helping to protect our work
environment that complies with laws and regulations. I thank you for your commitment and contribution
to NLCS, but most importantly, to our residents.
NATIONAL LUTHERAN COMMUNITIES & SERVICES