Code Of Conduct

Code Of Conduct

Origination 03/2019 Owner Lawrence Jordan III: NLCS General Counsel and CCO
Last Approved 02/2021 Policy Area Compliance
Last Revised 02/2021
Next Review 02/2023
NLCS Guiding Principles in Practice Two are better than one, because they have a good reward for their toil. For if they fall, one will lift up the other; but woe to one who is alone and falls and does not have another to help. Ecclesiastes 4: 9 -10 (NRSV)


  1. We will respect each other's work space, (e.g. respect meetings, conversations or phone calls already in progress, and closed doors).
  2. We use basic principles of common courtesy: saying hello, please, thank you, you are welcome, or my pleasure.
  3. We never intentionally subvert or surprise another partner in public. When this happens accidently we go to them quickly, explain the situation, ask forgiveness, and plan together how to correct the situation.
  4. We are sensitive to others' workload and deadlines.
  5. While we can disagree behind closed doors, we will work to support each other with our teams and in public.
  6. We will be thoughtful enough to know when our work will impact a partner's sandbox (e.g., building a new policy/procedure, visiting another location, creating a program that is different than other parts of the organization, or dealing with a personnel issue) and will work with them in advance to minimize the fall out.


  1. We earn the right to be heard by actively listening to one another, seeking first to understand.
  2. We welcome other members to our work spaces.
  3. We suspend our disbelief and counter-points when engaging one another; we state our disagreement or other opinion respectfully.
  4. We are aware of our surroundings so that confidential or private matters are not discussed in public areas.
  5. We take responsibility and are accountable for communicating information to our team members.
  6. We recognize the power of words to shape NLCS and impact one another; accordingly we use words exclusively to advance the organization and build each other up.


  1. We will give priority to and respect other's schedules, and keep appointments. When there is a need to postpone or cancel, we give as much notice as possible. When someone must return to their place of work after their shift has ended, we will respect their time and be mindful of interrupting during time off; including differences in schedules e.g. staff that work night shifts sleep during the day.
  2. We will maintain focus in meetings by muting phones, closing laptops, and avoiding other distracting and de-focusing behaviors. We realize in certain circumstances, employees in specialized roles may need to keep their device on, and they should advise the group at the start of the meeting of the possible interruption.
  3. We will begin and end meetings on-time.
  4. We use email with tact and thoughtfulness, as it is easy to misunderstand tone in emails. We answer emails/voice mails in a timely way (within 48hrs unless there are extenuating circumstances).
  5. We will actively look for ways to manage expense and prize being a financially fit organization, positioning us for a healthy today and hope-filled tomorrow.
  6. We will seek to find synergies whether it is people, processes, or materials to keep NLCS streamlined and efficient, allowing us to more readily grow and take on new challenges.


  1. We provide service to our customers (e.g. residents/patients, their families, each other, our teams/departments, board members, vendors, clients, visitors/guests, volunteers, the constituent synods, and the greater communities in which we serve).
  2. We smile; it's free and does wonders.
  3. We spend time getting to know our customers, their needs, desires, hopes, and wants.
  4. We make our customers our priority by treating them each as unique and important, attending to details to ensure their experience with us surpasses their expectation, helping them find solutions that are meaningful to them, and following up to ensure satisfaction in the delivery of service.
  5. We understand that every action we take can be directly tied to our customers' needs/desires. We believe that the details matter and act accordingly.
  6. We serve motivated by love for our neighbor and based on a model of Christian charity.


  1. We are partners, strong and resolved who will inevitably have conflict. Even at these times we start from a position of respect and believe that doing so can make us more effective as individuals, a team, and an organization.
  2. We own our thoughts, feelings, and actions, and work diligently to understand those of our partners'. When we are confused by a perceived gap between someone's behavior and position we acknowledge our reaction and ask for clarity (e.g. when you said you were calm but raised your voice it makes me think you're losing control, can you help me understand what happened?)
  3. We proactively seek resolution, giving time and space when requested, but not isolating partners with whom we have disagreements.
  4. We work directly with partners with whom we have issue, not involving others until we have first worked with the other individual. When we do involve others it is to have them come with us as we try to resolve the issue together.
  5. When someone comes to us with an issue about another we first ask if they have spoken to them. If they have not, we re-direct before engaging the issue. If they have, we go to listen and gain understanding from both parties and mediate a solution.
  6. When a partner chooses to break relationship and trust by not acting in accordance with these Principles in Practice or the spirit which they represent, individual team members are expected to document the offense(s), directly address the individual informing them of their course of action, and elevate the issue to their supervisor for resolution.

Scope of our Program

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
following services:

  • Skilled Nursing
  • Assisted Living
  • Independent Living
  • Home Care
  • Hospice

Compliance Officer

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.

Compliance Program Management

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
and integrity.

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.