Finding 564106 (2024-001)

Significant Deficiency
Requirement
E
Questioned Costs
-
Year
2024
Accepted
2025-06-06

AI Summary

  • Core Issue: The Organization lacks adequate internal controls for tracking eligible participants in the Staff Sergeant Fox Suicide Prevention Grant Program.
  • Impacted Requirements: There are no policies for participant assessment and release, leading to incomplete records and potential eligibility issues.
  • Recommended Follow-Up: Implement a tracking system for participants, update policies for assessments, and ensure all records are maintained and cross-referenced regularly.

Finding Text

2024-001 Participant Tracking Assistance Listing Number: 64.055 Name of Program and Cluster: Staff Sergeant Fox Suicide Prevention Grant Program Agency: U.S. Department of Veterans Affairs E - Eligibility Significant Deficiency Condition The Organization does not have sufficient internal controls over participants in the system. Criteria Services are to be provided to eligible individuals and their families through outreach, provision or coordination of suicide prevention services, and connection to VA and community resources. Eligible individuals include veterans and their family members and they must be at risk of suicide. Cause The Organization had difficulty providing a listing of eligible and active participants by contract or fiscal year. Additionally, as noted by the Department of Veterans Affairs (VA) audit of the program issued in March 2025, program agreements were not on file for participants and the Organization did not have a policy element requiring Patient Health Questionnaire (PHQ-9) assessment completed with a staff member. The VA audit also identified that there is no policy for releasing program participants. Effect The Organization was not able to produce a complete listing of all active participants for the period under audit. Although no eligibility compliance failures were noted during testing, there is no confirmation that the complete population for the period under audit was tested. Recommendation RBT recommends that the Organization track participants outside of the online portal including date enrolled and discharge date, to ensure that all participants who receive services within a contract year or fiscal year are eligible, uploaded to the portal and deactivated in a timely manner when discharged. The portal should be periodically cross referenced to the independent list maintained. RBT also recommends policies are updated and required assessment and release forms are maintained on file. Response See Corrective Action Plan

Corrective Action Plan

The person responsible for the correcting the finding and timeline are as follows: The Director of Veterans Programs, Alyssa Carion, Due Date: May 1, 2025. Regarding finding #2024-001, all items identified have been addressed and the due date has been met. All missing program agreements noted in the SSG Fox audit have been loaded to participant files. Policy and procedures have been updated to state that the patient health questionnaire must be completed by a staff member and a policy for releasing program participants has been added. Tracking participants outside of the online portal is in place and includes enrollment date, disenrollment date for all clients form program inception. In addition, a monthly control is in place to review the spreadsheet o ensure all documents are included.

Categories

Eligibility Significant Deficiency Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

Other Findings in this Audit

  • 1140548 2024-001
    Significant Deficiency

Programs in Audit

ALN Program Name Expenditures
64.055 Staff Sergeant Parker Gordon Fox Suicide Prevention Grant Program $573,904
93.788 Opioid Str $130,833
93.959 Block Grants for Prevention and Treatment of Substance Abuse $91,919
14.267 Continuum of Care Program $72,691
14.231 Emergency Solutions Grant Program $55,068
14.218 Community Development Block Grants/entitlement Grants $22,148
21.027 Coronavirus State and Local Fiscal Recovery Funds $7,254