Finding 1191631 (2025-003)

Material Weakness Repeat Finding
Requirement
E
Questioned Costs
-
Year
2025
Accepted
2026-03-27

AI Summary

  • Core Issue: The Association failed to retain documentation proving that participants met eligibility requirements for the Suicide Prevention Grant Program.
  • Impacted Requirements: Compliance with eligibility criteria outlined in the Hannon Act, specifically regarding documentation of at-risk individuals.
  • Recommended Follow-Up: Implement a process where multiple individuals review and verify the eligibility checklist before approving participants to ensure compliance.

Finding Text

2025-003 Material Weakness in Internal Control over Compliance and Noncompliance – Eligibility Name of Federal agency U.S. Department of Veterans Affairs Identification of Assistance Listing number and title: 64.055 Staff Sergeant Parker Gordon Fox Suicide Prevention Grant Program Federal award identification number and year: AK-SSG-1461-22 Criteria or specific requirement: Per §201(q)(4) of Hannon Act, an eligible individual is a person at risk of suicide who is one of the following: (1) A Veteran as defined in 38 U.S.C. 101, (2) an individual described in 38 U.S.C. 1720I(b), or (3) an individual described in 38 U.S.C. 1712A(a)(1)(C)(i) through (iv). See Section III. Participant Eligibility for details on how Staff Sergeant Parker Gordon Fox Suicide Prevention Grant Program grantees determine participant eligibility. Condition: To ensure services are provided only to eligible individuals, the Association uses a review checklist outlining the program’s eligibility requirements. We noted that the Association did not retain documentation of this completed checklist. Cause: The controls in place were not operating effectively to ensure eligibility requirements were met or that documentation of eligibility was retained. Effect or potential effect: The Association is out of compliance with the program eligibility requirements. Questioned Costs: None Context: For this program, a sample of eight individuals who participated was tested for compliance with eligibility requirements. Of the eight individuals tested, six did not have documentation retained to support that eligibility requirements were met. Additionally, six did not have documentation demonstrating the use of the eligibility checklist implemented by the Association. The Association was unable to provide any eligibility documentation for two of the sampled individuals. Identification of Repeat Finding: Not applicable. Recommendations: We recommend that, as part of the Association’s internal control structure over compliance with Uniform Guidance, the eligibility checklist be reviewed by more than one individual to verify that all eligibility requirements are met before an individual is approved to participate in the program. Views of Responsible Officials: Management agrees with the finding and has set up a corrective action plan. Refer to Corrective Action Plan.

Corrective Action Plan

Finding 2025-003: Material Weakness in Internal Control over Compliance and Noncompliance – Eligibility Program: 64.055 Staff Sergeant Parker Gordon Fox Suicide Prevention Grant Program Planned Corrective Action: To address the identified material weakness and ensure future compliance with SSG Fox SPGP eligibility and documentation requirements, the organization has implemented the following systemic enhancements: • Standardized Eligibility Controls: The organization has developed and deployed a mandatory Case File Compliance Checklist for all program participants. This control ensures that all federally mandated documentation—including signed program agreements, grievance procedures, religious protections, individualized service plans, and all five required baseline mental health screenings—is present and verified for every file. • Enhanced Management Oversight: To ensure the effectiveness of these controls, the Department Director has implemented a Monthly Quality Assurance (QA) Review. On a monthly basis, the Director will perform a formal audit of active case files to verify compliance. This review will be documented via a formal sign-off, providing a clear audit trail of supervisory oversight. • Records Retention & Security: Management oversight has been expanded to include specific verification of Data Integrity and Retention. Monthly reviews will ensure that all required documentation is maintained in accordance with 2 CFR § 200 standards—ensuring records are secure, unalterable, and readily accessible for future audits. • Continuous Professional Development: The organization has institutionalized a Mandatory Training Curriculum. All relevant staff will undergo initial onboarding and recurring periodic training focused on SSG Fox SPGP compliance standards, participant eligibility, and rigorous documentation procedures. • Personnel Realignment: The organization has undergone a restructuring of the program staff to ensure that all personnel are fully aligned with the agency's internal control environment and commitment to federal compliance. Anticipated completion date: April 30, 2026 Contact Information: Louise Chikigak, Chief Financial Officer, (907) 222-4250

Categories

Eligibility Material Weakness Internal Control / Segregation of Duties

Other Findings in this Audit

  • 1191628 2025-002
    Material Weakness Repeat
  • 1191629 2025-002
    Material Weakness Repeat
  • 1191630 2025-002
    Material Weakness Repeat

Programs in Audit

ALN Program Name Expenditures
93.224 HEALTH CENTER PROGRAM (COMMUNITY HEALTH CENTERS, MIGRANT HEALTH CENTERS, HEALTH CARE FOR THE HOMELESS, AND PUBLIC HOUSING PRIMARY CARE) $2.37M
15.U01 477 Education & Training $2.30M
16.841 VOCA TRIBAL VICTIM SERVICES SET-ASIDE PROGRAM $2.17M
93.600 HEAD START $604,338
93.243 SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES PROJECTS OF REGIONAL AND NATIONAL SIGNIFICANCE $599,151
15.022 TRIBAL SELF-GOVERNANCE $552,431
93.526 GRANTS FOR CAPITAL DEVELOPMENT IN HEALTH CENTERS $501,507
64.055 STAFF SERGEANT PARKER GORDON FOX SUICIDE PREVENTION GRANT PROGRAM $459,188
93.210 TRIBAL SELF-GOVERNANCE PROGRAM: IHS COMPACTS/FUNDING AGREEMENTS $457,214
15.U02 477 Education & Training $448,720
93.104 COMPREHENSIVE COMMUNITY MENTAL HEALTH SERVICES FOR CHILDREN WITH SERIOUS EMOTIONAL DISTURBANCES (SED) $412,697
93.612 NATIVE AMERICAN PROGRAMS $391,587
93.563 CHILD SUPPORT SERVICES $387,066
66.926 INDIAN ENVIRONMENTAL GENERAL ASSISTANCE PROGRAM (GAP) $331,002
93.788 OPIOID STR $285,148
15.032 INDIAN ECONOMIC DEVELOPMENT $151,710
93.047 SPECIAL PROGRAMS FOR THE AGING, TITLE VI, PART A, GRANTS TO INDIAN TRIBES, PART B, GRANTS TO NATIVE HAWAIIANS $136,552
93.092 AFFORDABLE CARE ACT (ACA) PERSONAL RESPONSIBILITY EDUCATION PROGRAM $126,268
93.762 A COMPREHENSIVE APPROACH TO GOOD HEALTH AND WELLNESS IN INDIAN COUNTY – FINANCED SOLELY BY PREVENTION AND PUBLIC HEALTH $118,915
93.671 FAMILY VIOLENCE PREVENTION AND SERVICES/DOMESTIC VIOLENCE SHELTER AND SUPPORTIVE SERVICES $116,082
93.237 SPECIAL DIABETES PROGRAM FOR INDIANS DIABETES PREVENTION AND TREATMENT PROJECTS $115,619
93.658 FOSTER CARE TITLE IV-E $112,481
45.311 NATIVE AMERICAN AND NATIVE HAWAIIAN LIBRARY SERVICES $103,805
93.587 PROMOTE THE SURVIVAL AND CONTINUING VITALITY OF NATIVE AMERICAN LANGUAGES $99,782
93.653 INDIAN HEALTH SERVICE DOMESTIC VIOLENCE PREVENTION PROGRAMS $99,765
10.182 PANDEMIC RELIEF ACTIVITIES: LOCAL FOOD PURCHASE AGREEMENTS WITH STATES, TRIBES, AND LOCAL GOVERNMENTS $91,263
94.002 AMERICORPS SENIORS RETIRED AND SENIOR VOLUNTEER PROGRAM (RSVP) 94.002 $89,002
93.107 AREA HEALTH EDUCATION CENTERS $76,637
93.800 ORGANIZED APPROACHES TO INCREASE COLORECTAL CANCER SCREENING $75,000
93.045 SPECIAL PROGRAMS FOR THE AGING, TITLE III, PART C, NUTRITION SERVICES $68,246
11.307 ECONOMIC ADJUSTMENT ASSISTANCE $68,089
66.920 SOLID WASTE INFRASTRUCTURE FOR RECYCLING INFRASTRUCTURE GRANTS $65,043
16.587 VIOLENCE AGAINST WOMEN DISCRETIONARY GRANTS FOR INDIAN TRIBAL GOVERNMENTS $61,362
66.202 CONGRESSIONALLY MANDATED PROJECTS $49,913
93.575 CHILD CARE AND DEVELOPMENT BLOCK GRANT $47,771
93.054 NATIONAL FAMILY CAREGIVER SUPPORT, TITLE VI, PART C, GRANTS TO INDIAN TRIBES AND NATIVE HAWAIIANS $46,611
21.027 CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS $44,239
93.231 EPIDEMIOLOGY PROGRAM $42,778
10.558 CHILD AND ADULT CARE FOOD PROGRAM $38,625
93.497 FAMILY VIOLENCE PREVENTION AND SERVICES/ SEXUAL ASSAULT/RAPE CRISIS SERVICES AND SUPPORTS $33,028
66.034 SURVEYS, STUDIES, RESEARCH, INVESTIGATIONS, DEMONSTRATIONS, AND SPECIAL PURPOSE ACTIVITIES RELATING TO THE CLEAN AIR ACT $31,600
93.043 SPECIAL PROGRAMS FOR THE AGING, TITLE III, PART D, DISEASE PREVENTION AND HEALTH PROMOTION SERVICES $13,246
93.568 LOW-INCOME HOME ENERGY ASSISTANCE $13,099
93.527 GRANTS FOR NEW AND EXPANDED SERVICES UNDER THE HEALTH CENTER PROGRAM $10,652
15.643 ALASKA MIGRATORY BIRD CO-MANAGEMENT COUNCIL $8,862
93.071 MEDICARE ENROLLMENT ASSISTANCE PROGRAM $7,910
10.760 WATER AND WASTE DISPOSAL SYSTEMS FOR RURAL COMMUNITIES $7,131
93.053 NUTRITION SERVICES INCENTIVE PROGRAM $4,644
93.645 STEPHANIE TUBBS JONES CHILD WELFARE SERVICES PROGRAM $4,130