HITRUST CCSFP Dumps

HITRUST defines sample sizes for manual controls based on the frequency of operation. For controls that operate weekly, the required sample size is 5 items. This ensures that the assessor can evaluate consistency over multiple weeks without excessive burden. For example, if access logs are reviewed weekly, five weeks of logs must be tested. A higher frequency (e.g., daily controls) requires larger samples, such as 25. Conversely, less frequent controls (e.g., monthly or quarterly) may only require 2 or 1 sample. The structured sampling methodology provides consistency across assessments, ensures sufficient evidence for scoring, and prevents under-testing of critical controls.

The HITRUST scoring methodology uses five maturity levels: Policy, Procedure, Implemented, Measured, and Managed. However, not every requirement statement includes Measured and Managed maturity elements. These two levels are applied selectively, particularly to requirements that lend themselves to performance monitoring and ongoing governance. For example, requirements involving logging, monitoring, and reporting often include “Measured” and “Managed” dimensions, while policy-only requirements may not. In r2 assessments, assessors should review the applicable requirement statements in MyCSF to see which maturity levels are required. This ensures that maturity scoring is accurate and aligned with HITRUST’s intent. Therefore, the statement that Measured and Managed can be scored for some but not all requirements in r2 is True.

In a Validated Assessment, organizations are required to score Policy, Procedure, and Implementation maturity levels for all applicable requirements. The Measured and Managed levels are considered advanced maturity tiers and are not mandatory for every requirement. They are only scored where applicable, typically for controls involving monitoring, governance, or performance management. For example, requirements around continuous vulnerability scanning or incident response metrics may include Measured and Managed, while policy-only requirements do not. Therefore, while entities may choose to pursue Measured and Managed maturity for stronger assurance or competitive differentiation, they are not required for certification. Certification can still be achieved with strong performance in the foundational maturity levels (Policy, Procedure, Implementation).

The HITRUST CSF is structured around a hierarchical model:

Control Categories → 14 high-level groupings (e.g., Access Control, Incident Management).

Control Objectives → Define goals under each category.

Control References → Specific implementation requirements aligned to objectives.

This structure ensures traceability from high-level objectives down to actionable control requirements.

Option B describes NIST Cybersecurity Framework (CSF), not HITRUST.

Option A/C include COBIT, which is integrated but not the structural foundation.

Extract Reference (HITRUST CSF Overview, CCSFP Guide [0134]):

The CSF is organized into Control Categories, Control Objectives, and Control References.

Certification requires all Requirement Statements to meet the 62.5% threshold.

From the chart:

“The Privacy Officer...” scored 42, below 62.5.

“Antivirus clients have...” scored 62, also below 62.5.

Because there are Requirement Statements below threshold, the assessment will contain Required CAPs, and certification cannot be awarded until remediation.

Extract Reference (HITRUST CSF Scoring Methodology [0192]):

Certification requires all Requirement Statements to meet the minimum scoring threshold; scores below 62.5 prevent certification.

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.

In HITRUST assessments, grouping is allowed when multiple primary components (like firewalls) are functionally identical in terms of configuration, management, and security controls. If all firewalls share the same rule sets, firmware, patching schedule, and are managed consistently, they can be grouped as one for testing purposes. This prevents repetitive validation work across systems that present no material differences in control design or operation. However, grouping requires justification and supporting documentation, showing that the systems are identical. If variations exist (e.g., differing rule sets or management practices), each firewall must be treated as a separate component. Grouping improves efficiency in large environments but must be applied cautiously to maintain the accuracy and integrity of testing results.

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.

The Implemented maturity level measures whether a control is operating effectively in practice. Scoring is based on the proportion of evaluative elements in place. In this scenario, two of the four required elements are implemented. This equates to 50% compliance, so the correct score is 50. For example, if a firewall control requires four items (documented rules, change management process, monitoring, and testing), and only two are in place, the organization is halfway compliant. This method ensures that partial implementation is acknowledged but also highlights gaps needing remediation. Scores of 0, 25, or 75 would not accurately reflect two of four elements, making 50 the correct value.

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.

Only in r2 assessments can organizations carve out third-party controls as not applicable if the responsibility lies entirely with a third party (e.g., inherited from a cloud provider).

In e1 and i1 assessments, carve-outs are not allowed because they are standardized, prescriptive frameworks.

Interim assessments are continuations of r2 certifications and do not allow carve-outs beyond the initial scope.

Extract Reference (HITRUST CSF Inheritance and Scoping Guidance [0116]):

Third-party carve-outs as N/A are only permitted in r2 assessments, as i1 and e1 follow prescriptive control sets.

The NIST Cybersecurity Framework (CSF) Report in HITRUST is a derivative output that is automatically generated within the MyCSF platform. When an entity completes a HITRUST assessment (e1, i1, or r2), MyCSF uses the mapping of HITRUST control requirements to the NIST CSF categories and subcategories to produce the report. Because these mappings are embedded into the framework, assessors do not need to perform additional testing, create mappings manually, or provide separate evidence. The effort invested in validating HITRUST requirement statements is sufficient, and MyCSF generates the NIST CSF alignment report as an output. This provides organizations with the ability to demonstrate NIST CSF alignment to stakeholders without duplicating work. Therefore, additional work is not required from assessors—making the correct answer No.

The scoring model in HITRUST is hierarchical. Each Requirement Statement is scored individually across maturity levels (Policy, Procedure, Implemented, Measured, Managed). These scores roll up into Control References, which represent collections of related requirement statements. The average of Control References within a domain determines the Domain Score. Finally, domain scores are used to evaluate whether certification thresholds are met (e.g., minimum domain score of 71 for r2 certification). This hierarchical averaging ensures that deficiencies in individual requirements are reflected in higher-level scores, promoting balance across all controls within a domain.

The HITRUST e1 and i1 assessments are streamlined, moderate-effort assurance models designed to evaluate an entity’s implementation of essential cybersecurity hygiene controls. These assessments focus on baseline security practices recognized across industries as foundational for protecting sensitive information. The e1 is intended for smaller organizations or those with limited resources, covering a subset of controls that address basic hygiene. The i1 provides expanded coverage beyond e1, testing against controls deemed critical for medium assurance levels. By contrast, the r2 is the most rigorous and risk-tailored assessment, covering a broader and more detailed control set. Targeted assessments are specialized and do not focus broadly on hygiene. Therefore, the e1 and i1 assessments are the correct answers.

For r2 certifications, HITRUST requires an interim assessment at the one-year mark to ensure ongoing compliance. The MyCSF platform automatically generates the interim assessment object 90 days prior to the certification anniversary date. This gives organizations and assessors adequate time to prepare, perform testing, and submit the interim assessment before the deadline. The auto-creation ensures that no certified entity misses the requirement, as failure to complete the interim would result in certification lapse. The 90-day window balances preparation time with the need for timeliness, ensuring continuous assurance between the initial validated assessment and the two-year certification cycle.

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

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).

In an i1 assessment, remediated controls must demonstrate sustained effectiveness before being retested. HITRUST requires a minimum of 90 days between remediation and reconsideration of the Implemented maturity level. This waiting period ensures that corrective actions are not only implemented but also consistently applied over time. For example, if patch management processes were deficient and then corrected, HITRUST wants to see proof that the new process has been followed successfully across multiple cycles. Immediate or short-term remediation is insufficient, as it may not show durability. This rule reinforces HITRUST’s focus on operational maturity and real-world assurance, preventing organizations from implementing “point-in-time fixes” just to pass assessments.

The HITRUST CSF integrates and harmonizes multiple authoritative sources and frameworks, including:

NIST SP 800-53 (security and privacy controls for federal systems).

ISO/IEC 27001/27002 (international information security management standards).

ISO 27799 (information security for healthcare).

HIPAA Omnibus Rule (U.S. healthcare privacy and security requirements).

NIST SP 800-37 (Risk Management Framework) is a methodology, not a control framework, so it is not included.

Extract Reference (HITRUST CSF Overview, CCSFP Guide [0005]):

The CSF integrates requirements from ISO, NIST, HIPAA, and other authoritative sources to create a unified control framework.

Correct responses: NIST SP 800-53, ISO 27799, ISO 27001/2, HIPAA Omnibus Rule.

The AI Risk Assessment compliance factor is used to scope AI-related controls in assessments.

However, the HITRUST AI Security Certification requires assessment of AI Security requirements, not just the AI Risk Assessment factor.

Thus, the statement is incorrect.

Extract Reference (HITRUST AI Security Factor Guidance [0007]):

The AI Risk Assessment factor scopes AI-related controls but does not by itself equate to AI Security Certification.

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.

HITRUST distinguishes between grouped and ungrouped components. When primary components (e.g., servers, databases, firewalls) are not grouped, they must be tested individually. This is because each ungrouped component may have unique configurations, operational practices, or control implementations, meaning sampling would not yield accurate results. Sampling is only permitted when components are grouped and proven to be functionally identical. In ungrouped situations, the assessor must test each component to validate control effectiveness. This ensures accuracy in scoring and avoids the risk of overlooking control failures in heterogeneous environments. Therefore, when components remain ungrouped, the assessor is required to test all components within scope and cannot rely on sampling methods.

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 requires strict independence within the External Assessor QA process. The Quality Assurance Reviewer must be independent of the engagement team to provide unbiased oversight. This role cannot be performed by the Engagement Executive, who is directly responsible for the client relationship and delivery of the assessment. Allowing the same individual to serve both roles would create a conflict of interest and undermine the credibility of the QA review. Instead, assessor organizations must designate separate personnel: the Engagement Executive to oversee project execution and a QA Reviewer to confirm accuracy, consistency, and compliance with HITRUST methodology. This separation supports objectivity and enhances the reliability of the assurance program.

In HITRUST scoring, deficiencies are identified when maturity levels fall below required thresholds for certification. In this case, the Policy, Procedure, and Implementation levels are not fully compliant, with scores of 50%, 50%, and 75% respectively. For certification-critical controls, HITRUST requires 100% Implementation, supported by adequate Policy and Procedure. Since the Implementation score is not at 100% and supporting maturity levels are below full compliance, this results in a Required Corrective Action Plan (CAP). The CAP ensures the organization addresses deficiencies through remediation. Unlike optional CAPs, which may apply to non-critical requirements, required CAPs must be documented and remediated to achieve certification. Thus, the correct classification of this scoring outcome is a Required CAP.

Organizations may conduct multiple assessments simultaneously in MyCSF. This may occur when an organization is pursuing different assurance levels (e.g., an r2 assessment for certification while also preparing an i1 for a customer request). It can also happen when separate business units or subsidiaries perform assessments concurrently. MyCSF supports multiple active assessment objects, allowing organizations to scope them independently while managing shared evidence, inheritance, and CAPs across assessments. However, care must be taken to ensure that evidence collection, assessor validation, and QA submissions do not overlap in a way that confuses reporting. HITRUST also provides analytics and dashboards that allow organizations to track multiple assessments at once.

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.

Illustrative Procedures are example testing steps provided in HITRUST to help assessors evaluate requirement statements consistently. They are not mandatory, but they serve as a guide for developing tailored testing procedures. Their uses include:

Implementation testing guidance (B): They show assessors what evidence to look for and how to test control performance.

Optional procedures (C): Organizations and assessors may adapt or replace them with equivalent procedures.

Test plan foundation (D): Assessors use them as a starting point to design their own testing plans, ensuring consistency and thoroughness.

Illustrative Procedures are not used for maintaining consistency between the entity and assessor responses (A), since testing must remain objective and independent. Their purpose is to promote consistent evaluation and reduce ambiguity.

Testing of HITRUST CSF requirements follows structured assurance procedures. It includes:

Interviewing personnel to validate understanding and confirm processes.

Sampling populations to ensure controls operate consistently.

Examining documentation such as policies, logs, and records.

Testing the technical implementation to verify system configurations and operational effectiveness.

“Remediating deficient controls” is not part of the testing process itself; it comes afterward as part of remediation.

Extract Reference (HITRUST CSF Assurance Program, CCSFP Training Guide):

Testing involves interviews, examination of documentation, inspection of technical implementations, and sampling populations to assess control design and operating effectiveness.

Regulatory factors are applied to scope based on legal, contractual, or regulatory obligations.

If an entity is required to comply with six regulatory factors, then all six must be included in the assessment scope.

Excluding any would result in an incomplete or non-compliant scope.

Extract Reference (HITRUST CSF Scoping Guidance [0088]):

All regulatory factors applicable to the entity’s obligations must be included in scope.

Illustrative Procedures in MyCSF serve as guidance, but they are not prescriptive or exclusive.

Assessors must exercise professional judgment and may tailor or supplement procedures as appropriate to validate the requirement.

Limiting testing solely to the tool’s Illustrative Procedures would contradict the principle of risk-based, flexible assessment.

Extract Reference (HITRUST Assessor Guidance [0054]):

Illustrative Procedures are examples to guide testing. Assessors may and should use additional or alternative procedures where necessary to adequately validate controls.

HITRUST conducts a QA review of every validated assessment to confirm that assessors followed the methodology and applied consistent testing. QA does not re-test every control; instead, HITRUST selects a sample of Control Objectives across the assessment. For each sample, HITRUST reviews assessor notes, evidence, and testing procedures to ensure accuracy and completeness. This sampling approach balances efficiency with assurance, allowing HITRUST to evaluate the assessor’s work without duplicating the entire validation process. If issues are found, QA may expand its review or return the assessment for clarification. This process ensures that validated assessments meet HITRUST’s quality standards before reports or certifications are issued.

The Readiness Assessment is designed to give organizations flexibility when evaluating their security and compliance posture. Unlike validated assessments, which are bound by specific methodologies, thresholds, and QA requirements, the readiness format allows entities to scope assessments more freely. This includes the ability to select any HITRUST authoritative source, such as HIPAA, PCI-DSS, NIST, ISO, or GDPR, for self-assessment purposes. The readiness option is often used for gap analysis, remediation planning, and preparing for a future validated assessment. Since the results are not submitted to HITRUST QA, organizations can tailor the assessment to their needs without external restrictions. Neither e1, i1, nor r2 assessments provide this level of flexibility, as those validated assessments are standardized and tightly controlled.

Unlike validated assessments, Readiness Assessments can be performed without a paid MyCSF subscription. HITRUST provides tools and options for organizations to conduct readiness reviews either directly in MyCSF (for subscribers) or through external assessor support without requiring a subscription. This flexibility allows organizations to test their preparedness and identify gaps before committing to the cost of a subscription or validated assessment. While subscription provides additional benefits (e.g., analytics, inheritance, reporting dashboards), it is not mandatory for readiness. This ensures that even smaller organizations or first-time users can access HITRUST readiness services without financial barriers.

Preview Profile in MyCSF allows organizations to model different scoping scenarios and view how many Requirement Statements would apply.

This can be done without formally updating the assessment object.

“Applicable Controls” and “Preview Changes” are related to finalized objects, while “Create Assessment” launches a new one.

Extract Reference (MyCSF Guidance [0181]):

The Preview Profile feature allows subscribers to compare Requirement Statement counts under different scenarios without committing changes to the assessment object.

Correct response: Preview Profile.

The Interim Assessment (required at the 1-year mark during a 2-year r2 Certification period) ensures continued compliance. It does not retest all Requirement Statements from the initial assessment. Instead, it involves:

Testing all CAPs from the original validated assessment.

Confirming no significant changes occurred in the in-scope environment.

Testing a random sampling of Requirement Statements, as chosen by the MyCSF tool, to confirm continued adherence.

Completing assessor assertions to verify compliance status.

Extract Reference (CCSFP Study Guide, Interim Assessment Requirements [0046]):

Interim Assessments focus on testing CAPs, environmental change confirmation, assessor assertions, and a sample of Requirement Statements; full retesting of all controls is not required.

HITRUST’s MyCSF platform allows organizations to manage CAPs centrally. When a CAP is created in one assessment object, it can be tracked and viewed across other assessments. This capability gives organizations a consolidated view of open remediation items, progress, and deadlines. Centralized CAP management supports ongoing compliance by ensuring that unresolved issues are not siloed within individual assessments. It also enables organizations to demonstrate to assessors and stakeholders that CAPs are actively managed across their environment. This central view provides efficiencies for entities undergoing multiple assessments simultaneously.

The e1 assessment focuses on essential cybersecurity hygiene controls. To achieve certification, the Implemented maturity level must demonstrate full (100%) compliance for each requirement statement. Partial implementation (such as 50%) indicates that the control is not consistently applied or lacks complete coverage across systems and users. HITRUST emphasizes the Implemented level in e1 because it represents proof that foundational safeguards are actively functioning. Scoring 50% would fall into the “Partially Compliant” category, which is insufficient for certification. Even if policies and procedures exist, HITRUST requires controls to be fully implemented for an e1 certification outcome. This strict requirement helps ensure that entities with lower assurance models still achieve a baseline of strong operational security.

HITRUST certifications apply to implemented systems and environments, not products, individuals, or facilities. For example, a healthcare provider may certify its electronic health record (EHR) platform, data center, and IT operations supporting PHI. HITRUST does not certify products like software applications sold to customers; instead, it certifies how organizations implement and operate them securely. Similarly, while HITRUST offers professional credentials like CCSFP or CHQP for people, these are certifications of knowledge, not organizational assurance. Facilities are included in assessments as scoping components but are not independently certified. The certification is always tied to an organization’s operational environment as validated through a CSF assessment.

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.

HITRUST Assurance Advisories (HAAs) are issued when necessary to communicate important updates, clarifications, or changes impacting the CSF Assurance Program. These advisories are not bound to a fixed schedule (monthly, quarterly, or annually), but rather published as needed.

Extract Reference (HITRUST CSF Assurance Program, CCSFP Content [0167]):

There is no formal schedule for issuing HITRUST Assurance Advisories; they are published on an as-needed basis to communicate relevant updates.

Correct response: There is no formal schedule.

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.