CCSFP Sample Questions Answers

When relying on third-party reports (such as SOC 2 reports) to satisfy HITRUST requirements, only reports with sufficient detail can be used. HITRUST requires:

A clear description of scope (A) to confirm applicability to the assessed environment.

A list of procedures performed (C) so assessors can evaluate whether testing covered relevant controls.

Conclusions reached for each test (E) to provide assurance about the effectiveness of tested controls.

While an executive summary may be helpful for context, it lacks sufficient detail to serve as valid reliance evidence. Similarly, “completed remediation” of exceptions (B) is not required; rather, the report must document exceptions transparently. Assessors remain responsible for verifying that reliance reports are current, relevant, and issued by qualified independent auditors.

HITRUST defines sample sizes for manual controls based on their frequency of operation. For daily controls, such as system log reviews or daily backup checks, the required sample size is 25 items. This sample size is designed to provide sufficient evidence that the control is consistently applied over time while remaining manageable for assessors. For weekly controls, the sample size is smaller (5), and for monthly or quarterly controls, it is smaller still (2 or 1). The 25-item rule ensures daily processes are tested across a meaningful timeframe (roughly a month of working days) to validate reliability. This standardized approach ensures comparability across assessments and prevents under-testing.

Insights Reports are designed to provide deeper analytics and benchmarking than standard e1 reports.

They expand visibility into authoritative sources, industry comparisons, and organizational insights beyond what a basic e1 delivers.

Extract Reference (HITRUST Assurance Program Reporting [0042]):

Insights Reports provide a more comprehensive analysis, including authoritative source mapping and benchmarking, beyond the standard e1 report.

HITRUST applies the CAP requirement at the Control Reference level. A CAP is required when the Control Reference score falls at 70 or below and Implementation maturity is not at 100%. In this case, the aggregate score is 72.5, which is above the certification threshold of 71. Even though there are gaps within individual requirement statements, the Control Reference as a whole is performing above the threshold, meaning a CAP is not mandatory. However, the gaps must still be documented, and remediation may be encouraged, but they will not block certification. This policy ensures that CAPs are only required where deficiencies present material risk to certification.

HITRUST does not permit marking a requirement statement “Not Applicable” simply because most of the evaluative elements don’t apply. Requirement statements are mandatory unless a legitimate scoping or regulatory justification supports exclusion. For example, a control related to cardholder data could be marked N/A only if the organization does not process credit cards. However, if even one evaluative element applies, the requirement must be scored, and the non-applicable elements may be documented as part of evidence. HITRUST QA reviews all N/A designations, requiring organizations to justify exclusions in the Subscriber Comments field. Improperly marking requirements as N/A may result in assessment rejection or mandatory CAPs.

Comprehensive and Detailed Explanation:

According to the HITRUST CSF Assurance Program, the reliance period for a point-in-time assessment is one year (12 months) from the assessment report date.

The statement claims a two-year validity, which is incorrect.

Reliance beyond one year would require an updated assessment or interim assessment for assurance continuity.

Extract Reference (HITRUST CSF Assurance Program, CCSFP Objectives [0078]):

Point-in-time reports can only be relied upon if issued within one year from the assessment start date; two years is not permitted.

The HITRUST CSF is not intended to replace existing regulatory frameworks such as HIPAA or security standards like NIST 800-53. Instead, the CSF harmonizes and integrates requirements from these and other authoritative sources into a single certifiable framework. For example, HIPAA Security Rule provisions and NIST 800-53 controls are mapped into the CSF domains and requirement statements. This enables organizations to demonstrate compliance with multiple frameworks through one assessment. However, the CSF does not eliminate or supersede the original obligations. Covered entities must still comply with HIPAA, and federal contractors may still need to align with NIST standards directly. The CSF serves as a consolidated implementation tool, not a legal or regulatory replacement.

HITRUST enforces strict evidence requirements to maintain credibility of assessment results. For Policy and Procedure maturity levels, if a score above 25% is claimed, the organization must link appropriate evidence (e.g., documented policies, standard operating procedures). For Implementation, Measured, and Managed, evidence must be provided whenever a score greater than 0% is claimed. This ensures that claims are supported by objective artifacts rather than assertions. Evidence can include policy documents, monitoring reports, logs, meeting minutes, or audit records. HITRUST QA verifies that evidence is linked to requirement statements at each maturity level. Without linked evidence, scores may be reduced or reverted during QA. This policy ensures transparency, accountability, and prevents overstatement of control effectiveness.

When a relying party requests an Insights Report covering AI risks, the appropriate selection in MyCSF is the A1 Risk Assessment. The A1 Security Assessment adds AI-related requirements to evaluate technical and governance safeguards for artificial intelligence systems. However, the A1 Risk Assessment is specifically designed to generate Insights Reports that highlight AI-related risk exposures, model governance practices, and data usage concerns. HITRUST distinguishes between these two factors to ensure organizations scope their assessment appropriately. By selecting the A1 Risk Assessment, the assessment object will include additional requirement statements aligned with AI risks, enabling the Insights Report output. This ensures stakeholders receive the necessary assurance information about the organization’s risk environment in relation to AI.

A validated assessment may or may not result in certification. Certification is granted only if the assessment meets HITRUST certification criteria, including required thresholds (e.g., ≥62.5% where applicable) and other program conditions. Thus, not all validated assessments receive certification.

“Certification is not automatic upon validation; only assessments meeting HITRUST certification criteria are eligible for certification.” [HITRUST CSF Assurance Program Overview, 0022]

All three validated assessment types—e1, i1, and r2—evaluate controls considered core to cybersecurity hygiene, though at different levels of assurance. For example, e1 is a low-effort model focusing on essential hygiene, i1 is a moderate-assurance model, and r2 is a comprehensive, risk-based model. Requirement statement counts can vary depending on the regulatory and organizational factors selected during scoping. For instance, adding PCI-DSS or HIPAA will increase requirement counts across all types. All assessment types also require testing of implementation, since evidence of operational control performance is mandatory for validation. The incorrect option is C: r2 assessments always include all 19 domains, and so do e1 and i1 assessments. What differs is the number of requirement statements in each domain, not the domains themselves.

The HITRUST CSF is a living framework designed to align with multiple regulatory and industry standards such as HIPAA, NIST, ISO, PCI DSS, and GDPR. While it is updated regularly to maintain alignment with these external sources, the update cycle is not strictly annual. HITRUST publishes updates as needed, typically in major releases (e.g., v9.1, v9.4, v11) and interim updates when regulatory changes occur. For example, significant updates may happen every 18–24 months, with minor updates issued in between. This flexibility allows HITRUST to remain responsive to evolving security, privacy, and compliance requirements rather than being bound to a fixed yearly schedule. Therefore, the statement that the CSF is always updated annually is False.

HITRUST’s risk-based approach includes incorporating regulatory factors relevant to an organization’s geographic and operational footprint:

Texas Health and Safety Code → Applicable since the hospital operates in Texas.

Massachusetts Data Protection Act → Applicable since the hospital operates in Massachusetts.

PCI-DSS → Required because the hospital processes credit card data.

Singapore Personal Data Act → Not applicable (hospital does not operate in Singapore).

Nevada Security of Personal Information Requirements → Not applicable (no presence in Nevada).

Extract Reference (HITRUST CSF Scoping & Tailoring Guidance [0013]):

Regulatory factors are selected based on where the organization operates and the type of data processed. For organizations in Texas and Massachusetts handling credit card data, applicable factors include Texas Health and Safety Code, Massachusetts Data Protection Act, and PCI-DSS.

The HITRUST CSF scoring rubric evaluates maturity across five levels: Policy, Procedure, Implemented, Measured, and Managed. To achieve certification in an r2 assessment, each domain must meet a minimum aggregate threshold of 71. Full compliance in Policy, Procedure, and Implementation (100% each) results in high scores that exceed the certification threshold. The Measured and Managed levels, while valuable for demonstrating monitoring and governance, are not required to be scored above zero to achieve certification. In this scenario, the organization demonstrates complete documentation and implementation of controls, which satisfies HITRUST’s certification criteria. Therefore, even with Measured and Managed at zero, the assessment can achieve certification because the foundational maturity levels provide sufficient assurance.

Fully Compliant = 100

Mostly Compliant = 75

Partially Compliant = 50

Somewhat Compliant = 25

Non-Compliant = 0

HITRUST assigns specific numeric values to compliance categories within the scoring rubric to standardize assessments. These categories translate qualitative assessments into quantitative scores:

Fully Compliant (100): All criteria met with complete and verified evidence.

Mostly Compliant (75): Most criteria met; minor gaps exist.

Partially Compliant (50): Roughly half of the evaluative elements are met.

Somewhat Compliant (25): Only a small fraction of the evaluative elements are satisfied.

Non-Compliant (0): No evidence of compliance.

These values are applied at the Requirement Statement level and then averaged upward into Control Reference and Domain scores. This quantification ensures consistency and supports certification thresholds such as the domain-level requirement of 71 for r2 certification.

CAP decisions are made at the Control Reference level, not both Requirement Statement and Control Reference levels. Individual requirement statements roll up into a control reference, and the control reference score determines whether a CAP is required. For instance, a low-scoring requirement may be present, but if the aggregated control reference score remains above the threshold, a CAP may not be required. Conversely, if the control reference score falls below the defined threshold, then a CAP is mandatory. This approach ensures consistency by focusing on control objectives as a whole rather than single requirements. Therefore, CAP decisions are not made independently at the requirement statement level, making the statement False.

The r2 Validated Assessment provides the highest level of assurance within the HITRUST portfolio. It includes all 19 CSF domains and applies a risk-based approach tailored to the organization’s industry, regulatory obligations, and technical environment. The r2 incorporates maturity level scoring (Policy, Procedure, Implementation, Measured, and Managed), allowing stakeholders to evaluate both control presence and long-term sustainability. It is also the only assessment type eligible for a two-year certification, provided interim requirements are met. By contrast, i1 and e1 assessments provide lower levels of assurance, designed for cybersecurity hygiene and medium-level assurance, respectively. Organizations with complex environments, sensitive data, or high regulatory expectations generally pursue r2 to provide maximum assurance to stakeholders.

When an assessor submits a validated assessment object to HITRUST, the QA intake process begins. HITRUST typically takes 3–5 business days to complete an initial review and decide whether to accept the submission into the QA pipeline or reject it due to deficiencies (such as missing evidence, incomplete CAPs, or improper scoping). Acceptance at this stage does not mean certification—it simply indicates that the assessment meets the minimum requirements to enter QA. If rejected, the assessor must correct the issues before resubmission. The 3–5 day timeframe ensures efficiency while maintaining rigor in intake quality checks.

Scoping an assessment involves identifying regulatory factors that apply to an organization’s operations. In this case, the entity is a pharmacy that accepts Medicare/Medicaid and processes credit cards. Medicare/Medicaid participation introduces obligations under CMS Minimum Security Requirements (High), which adds federal requirements specific to healthcare entities working with Centers for Medicare and Medicaid Services. Credit card acceptance triggers applicability of the Payment Card Industry Data Security Standard (PCI-DSS), a widely recognized standard for protecting cardholder data. Additionally, pharmacies often fall under the FTC Red Flags Rule, which applies to organizations that maintain consumer accounts and must protect against identity theft. By contrast, FISMA applies to federal agencies or contractors, not pharmacies, and FedRAMP applies only to cloud service providers working with the federal government. Therefore, the correct set of regulatory factors is FTC Red Flags Rule, PCI-DSS, and CMS Minimum Security Requirements (High).

When a requirement statement or control reference fails to meet the HITRUST scoring threshold, a Corrective Action Plan (CAP) may be required. CAPs represent formal remediation commitments that must be documented in the assessment object before submission to QA. Each CAP must include details such as the control deficiency, planned remediation steps, responsible parties, milestones, and expected completion dates. HITRUST QA will verify that all required CAPs are present before accepting the assessment for review. Without CAP documentation, the assessment submission is considered incomplete. This process ensures transparency and accountability and demonstrates to relying parties that the organization has a structured plan to close gaps. Therefore, the statement is True.

Certification can only be achieved through a Validated Assessment (not readiness).

Eligible assessment types for certification are:

e1 Validated Assessment

i1 Validated Assessment

r2 Validated Assessment

Readiness Assessments, Customized, or Targeted Assessments cannot result in certification.

Extract Reference (HITRUST CSF Assurance Program [0158]):

Only validated e1, i1, or r2 assessments are eligible for HITRUST certification.

HITRUST offers Rapid Assessments as a lightweight reporting option for organizations and their relying parties. These assessments provide high-level visibility without requiring large numbers of requirements. In fact, a Rapid Assessment may contain fewer than 60 requirement statements depending on scoping and factors selected. There is no requirement that an assessment or insights report exceed 60 requirements to qualify as a rapid assessment. Instead, the determination is based on the selected assessment type (e1, i1, or targeted factors) and whether the output is requested in “rapid” format. This flexibility allows small organizations or specific use cases to leverage HITRUST without unnecessary burden.

The Measured maturity level evaluates whether organizations actively monitor the effectiveness of controls. HITRUST defines seven criteria for Measured, including metrics, data collection, analysis, reporting, and corrective action tracking. If these seven criteria are fully met, scoring can begin at Tier 4 strength, reflecting a mature measurement process. In the example, system administrators are responsible for measuring firewall configuration security, and if they meet all seven criteria (such as reviewing firewall rules, analyzing logs, reporting deviations, and initiating remediation), the Measured compliance level can start at Tier 4. The assessor may then adjust scoring based on coverage and frequency, but the baseline is Tier 4 once all criteria are satisfied. This ensures consistent evaluation of advanced maturity levels across controls.

The HITRUST CSF transitioned to an industry-agnostic framework beginning with version 9.0. Prior to v9.0, HITRUST CSF was often perceived as heavily healthcare-focused, since HIPAA was embedded directly into the baseline controls. With v9.0, HIPAA was moved into the regulatory factor category, making it selectable during scoping rather than inherently included for all organizations. This change expanded the CSF’s applicability beyond healthcare, making it suitable for industries such as finance, technology, and government contractors. It also aligned with HITRUST’s vision of providing a “common security framework” that supports multiple industries while maintaining healthcare compliance capabilities through HIPAA as a regulatory overlay.

When the AI (A1) Security factor is selected during scoping, HITRUST does not add requirements across all 19 domains. Instead, it introduces specific requirement statements relevant to AI risks, such as data integrity, model governance, algorithm transparency, and monitoring. These requirements are mapped to domains most impacted by AI operations, like Information Protection, Risk Management, and Data Privacy. Domains unrelated to AI (for example, Facilities Security or Environmental Safeguards) may not receive any new requirements. This selective approach ensures that AI risk factors are incorporated appropriately without overloading domains unnecessarily. Thus, it is inaccurate to state that every domain is updated with AI-related requirements.

Corrective Action Plans (CAPs) represent identified gaps that must be tracked until they are fully remediated. Even if an organization remediates a CAP after an assessment is completed, the CAP remains part of the final validated report for transparency. The report will show the CAP along with its remediation status and closure details, but it cannot be deleted or excluded. This ensures stakeholders have a complete history of deficiencies and the corrective actions taken. CAPs demonstrate accountability and continuous improvement, which are central to HITRUST’s assurance model. Removing them would diminish trust and obscure the remediation journey, which is why HITRUST prohibits their removal post-assessment.

A validated assessment does not require a readiness assessment as a prerequisite.

A Readiness Assessment is optional and intended to help organizations self-identify gaps before a validated assessment.

A Validated Assessment involves an independent HITRUST Authorized External Assessor validating evidence and submitting results to HITRUST for quality assurance and potential certification.

Many organizations choose to do a readiness assessment first, but it is not mandatory.

Extract Reference (CCSFP Study Guide & HITRUST CSF Assurance Program [0020]):

Organizations may perform a readiness assessment prior to a validated assessment to identify gaps, but it is not required; validated assessments can be performed independently.

If management decides to add new systems mid-assessment, the assessor must ensure the assessment scope and related requirement statements reflect the change. In MyCSF, this means two actions: first, reverting all completed Requirement Statements so that the client can review and adjust responses for any new control impacts. Second, the assessor must update the “Scope of the Assessment” tab to include the new systems. This ensures that MyCSF recalculates applicable requirements based on the expanded scope. Removing authoritative sources or requesting a Bridge Certificate would not address this situation, as authoritative sources are regulatory mappings and bridge certificates are only used to extend certifications temporarily.

HITRUST requires that each of the 19 domains achieve a minimum score of 71 for an organization to qualify for r2 certification. This threshold ensures that entities maintain a consistent level of maturity across all control areas, rather than excelling in some while neglecting others. The 71 threshold is calculated from the weighted average of requirement statements within a domain, factoring in Policy, Procedure, and Implementation maturity scores (with Measured and Managed as applicable). If any domain falls below 71, the assessment may still produce a validated report, but it will not result in certification. This strict requirement highlights HITRUST’s emphasis on balanced coverage across all areas of security and privacy.

Comprehensive and Detailed Explanation:

Assessors must maintain independence and avoid conflicts of interest.

If David assisted in remediating a gap, he cannot also validate the remediation, as that would compromise objectivity.

HITRUST requires separation of consulting/remediation support from assurance/validation activities.

Extract Reference (HITRUST CSF Assurance Program Independence Standards [0141]):

External Assessors may not validate remediation efforts they directly assisted in, to preserve independence.

Comprehensive and Detailed Explanation:

HITRUST permits organizations to select from active versions of the CSF framework. While using the most current version is recommended, it is not mandatory. Companies may choose the version that best aligns with their compliance timelines, regulatory obligations, or contractual requirements.

The tool does not automatically select the version.

The assessor does not choose the version—the organization makes this decision.

Selecting any active version gives flexibility while maintaining recognized assurance validity.

Extract Reference (HITRUST CSF v11 Guidance, CCSFP Study Guide [0163]):

Organizations may use any active version of the HITRUST CSF for their assessment. While it is encouraged to adopt the most recent version, HITRUST allows organizations to choose the version that best meets their needs

The Offline Assessment function is initiated within the assessment object in MyCSF. This feature allows assessors to export requirement statements into an Excel spreadsheet format, which can then be used offline to collect responses, notes, and preliminary evidence. Once populated, the spreadsheet can be uploaded back into MyCSF to synchronize with the online assessment object. This capability is particularly useful when assessors or clients must work in environments with limited internet access or when they prefer batch updates. It is not launched from the landing page, analytics, or via the support desk; it is always tied directly to a specific assessment object.

When a Requirement Statement’s responsibility is shared between a client and service providers (e.g., cloud vendors or managed security providers), HITRUST requires a blended scoring approach. Assessors must evaluate all parties’ contributions and assign a composite score that reflects the total control environment. This prevents organizations from over-relying on inherited provider scores without demonstrating their own responsibilities (e.g., configuration, monitoring). It also prevents dismissing requirements as N/A since partial responsibility still exists. By combining the provider’s validated assessment results with the client’s implementation evidence, HITRUST ensures a complete and accurate reflection of risk. Sole reliance on provider scores would overlook gaps in client-side processes.

The Certified CSF Practitioner (CCSFP) designation, awarded through HITRUST Academy, is valid for two years from the date of certification. During this period, practitioners are recognized as trained professionals qualified to assist organizations in implementing, preparing for, and supporting HITRUST CSF assessments. Unlike certifications in some other frameworks, CCSFP does not require annual refresher training for continued validity. After the two-year period, practitioners must renew their certification, typically by retaking the CCSFP course or completing updated training to ensure knowledge of the latest HITRUST CSF version and Assurance Program changes. The two-year cycle aligns with HITRUST’s update cadence, ensuring practitioners remain current with evolving regulatory mappings, control requirements, and scoring methodology.

HITRUST certifications are valid for two years, not three.

Interim assessments are required at the 1-year mark to maintain certification status.

Even if an organization scored 100% across all 19 domains, the maximum certification term is two years.

Extract Reference (HITRUST CSF Assurance Program Guide [0095]):

HITRUST certifications are valid for a period of two years, contingent upon the successful completion of an interim assessment after year one.

In an i1 assessment, scoring follows a pass/fail logic tied to CAP requirements. If a Control Reference scores below the defined threshold (typically 83 for i1 assessments), any gaps within its requirement statements must be addressed with a required Corrective Action Plan (CAP). A score of 62 is below the threshold, meaning it cannot be accepted without remediation. This ensures organizations remediate key cybersecurity hygiene gaps, even in a moderate assurance assessment. Optional CAPs are not used in i1 assessments, as the assurance program emphasizes mandatory remediation for below-threshold controls. Certification cannot be granted with unresolved required CAPs. Therefore, the correct outcome for a score of 62 in an i1 Control Reference is a required CAP.

Marking a requirement statement “Not Applicable (N/A)” requires careful justification. In r2 assessments, compliance factors such as HIPAA, PCI-DSS, GDPR, or state-specific laws may trigger requirements that would not otherwise apply. Therefore, an assessor must verify that all compliance factors have been considered before permitting an N/A designation. For example, a requirement related to cardholder data might seem irrelevant unless PCI-DSS was selected as a compliance factor; in that case, it becomes mandatory. HITRUST QA scrutinizes N/A markings to ensure they are not misused to exclude applicable requirements. Incorrect use of N/A may result in CAPs or QA rejection. Thus, compliance factors must always be reviewed first to confirm whether the requirement is truly outside scope.

In an r2 assessment, CAP requirements are determined at the Control Reference level. If the aggregate score falls below the certification threshold of 71, and the Implementation maturity level is not at 100%, a Corrective Action Plan (CAP) must be documented. This ensures that organizations commit to remediating critical control deficiencies before certification can be finalized. CAPs must include clear details such as responsible parties, remediation steps, and timelines. Without CAPs, HITRUST will not accept the assessment for certification. Even if Policy or Procedure scores are strong, missing implementation creates unacceptable risk. Therefore, HITRUST mandates CAPs in these cases to close certification-critical gaps.

The A1 Security Assessment factor is an optional module that introduces requirements for evaluating the security and governance of AI-based systems. These requirements are mapped into HITRUST CSF across domains like risk management, monitoring, and governance. Importantly, the A1 factor is not restricted solely to r2 assessments. While r2 provides the most comprehensive assurance model, A1 can also be added to other eligible assessment types such as i1 when the scope involves AI risks. The factor is treated like any other regulatory or organizational factor in MyCSF—its selection generates additional tailored requirement statements. Therefore, the claim that A1 can only be added to r2 is inaccurate. The correct understanding is that A1 can apply to multiple assessment types, depending on scoping decisions.