CCSFP Certified CSF Practitioner 2025 Exam Question and Answers

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.

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.

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).

The Measured maturity level requires organizations to demonstrate structured metrics, analysis, and reporting across seven defined criteria. If these criteria are not met, the Measured level cannot receive any positive score. Instead, it defaults to Tier 0, representing Non-Compliant (0%) at this maturity level. This ensures that organizations cannot claim credit for partial or informal measurement practices. For example, if firewall logs are collected but never analyzed or reported, the criteria are not satisfied, and the Measured score remains Tier 0. Only once all seven criteria are satisfied can scoring begin at Tier 4 and be adjusted based on coverage and strength.

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 weighting of partially inherited scores in HITRUST is determined by HITRUST’s methodology, not by mutual agreement between the assessed entity and service provider.

Organizations may identify which portions of a requirement are inherited vs. managed internally, but the actual scoring mechanics are controlled by the HITRUST CSF Assurance methodology to ensure consistency.

Extract Reference (HITRUST CSF Inheritance Guidance [0190]):

Weighting for partial inheritance is calculated using HITRUST’s scoring methodology, not negotiated between entities.

When testing implementation, the population must include the full set of in-scope assets, not just a subset filtered by existing controls.

AV console (A) → only shows devices with AV installed; it would exclude noncompliant assets.

IT asset inventory (C) → provides the complete list of laptops, making it the proper source for random sample selection.

Risk register (D) → lists risks, not devices.

Capital assets only (B) → not comprehensive for all laptops.

Extract Reference (HITRUST Assessment Sampling Guidance, CCSFP [0173]):

Sampling must be based on the complete population from the IT asset inventory; reliance on control-based systems (e.g., AV console) introduces bias.

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.

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.

When an entity submits an assessment to their External Assessor, the responses are locked to preserve the integrity of the submission. However, changes can still be made if the assessor reverts a Requirement Statement back to the entity. This allows management to adjust responses, provide new evidence, or clarify details before the assessor finalizes validation. HITRUST itself does not revert requirement statements during the assessment phase, as that authority rests with the assessor. Once the assessment is submitted to HITRUST QA, responses cannot be modified. This process ensures proper control while still giving flexibility for corrections during the assessor review.

For an r2 Certification:

Certification is valid for two years, but an Interim Assessment must be performed at the 12-month mark to maintain certification status.

This ensures continuous compliance, validation of CAP progress, and confirmation of no significant scope changes.

Extract Reference (HITRUST Assurance Program, CCSFP Guide [0023]):

Interim Assessments are required 12 months after r2 certification to maintain certification validity for the second year.

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.

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.

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.

HITRUST provides sampling guidance in the CSF Assessment Methodology and scoring rubric for manual controls. Sample sizes are determined by the population of items and the control’s frequency. For a population of 56 items, the expected sample size is 8, following HITRUST’s defined sampling table. This approach is based on statistical sampling principles but simplified for consistent assessor use. The sample must be randomly selected and representative of the entire population to avoid bias. Larger populations require larger sample sizes, but at certain thresholds, the increase is incremental. For example, a population between 26–100 items requires a sample size of 8. This ensures sufficient testing coverage without requiring a full census. Therefore, the correct sample size for 56 items is 8.

The responsibility for defining the scope of an assessment lies with client management. The organization undergoing the assessment must identify which systems, applications, facilities, and business units are in scope. This decision is based on business objectives, regulatory requirements, contractual obligations, and the sensitivity of data being processed. External Assessors play a supporting role by reviewing scope decisions and ensuring they are reasonable and sufficient to meet assurance objectives. HITRUST does not define scope directly but requires that scope decisions be documented and defensible. An accurately defined scope ensures that the assessment reflects the organization’s risk exposure without omitting critical components. Mis-scoping can either undermine assurance or create unnecessary testing burden.

HITRUST issues certifications only for the HITRUST CSF (e.g., e1, i1, r2 certifications and designated privacy/AI certifications as defined by the program). While the CSF maps to and harmonizes with other frameworks and regulations (e.g., NIST SP 800-53, ISO/IEC 27001/27002, PCI-DSS), HITRUST does not issue certifications for those external standards.

“HITRUST provides certification against the HITRUST CSF. External standards and regulations are integrated as authoritative sources and mappings but are not certified by HITRUST.” [CCSFP Program Overview – Certifications & Mappings, 0017]

HITRUST uses a scoring scale from 0 to 100, with categories for Fully Compliant, Mostly Compliant, Partially Compliant, Somewhat Compliant, and Non-Compliant. A score of 37 falls into the “Somewhat Compliant” category. This reflects significant weaknesses in Policy, Procedure, or Implementation maturity levels. Such a low score indicates a gap that must be addressed. Depending on whether the control is required for certification, HITRUST may require a Corrective Action Plan (CAP). CAPs are required when certification-critical controls score below thresholds (e.g., Implementation not at 100% where required). Therefore, a Requirement Statement score of 37 would be treated as a gap with a possible required CAP, depending on its criticality within the certification process.

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.

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.

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.

HITRUST does not issue certifications limited solely to privacy-related requirements. While privacy is a critical part of the CSF—reflected in domains such as Data Protection & Privacy—HITRUST certifications require coverage of all 19 domains. This is because security and privacy are interdependent: without robust security, privacy cannot be protected. An entity may emphasize privacy controls during scoping and reporting, but certification itself is always tied to a full CSF assessment. Privacy-related frameworks, such as GDPR or HIPAA Privacy Rule, can be added as regulatory factors, which introduce additional privacy-focused requirements. However, the output will still be a standard HITRUST validated report or certification covering the entire environment, not a “privacy-only 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 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.

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 requires independent validation of security controls, and vulnerability testing is a critical part of that process. External assessors are expected to review vulnerability management programs and may conduct their own independent vulnerability testing to validate results. While many organizations perform internal scans, assessors may request additional testing or re-scans if evidence is insufficient. The notion that external assessors should “never” perform such testing is incorrect. In fact, the assurance program allows assessors to conduct testing directly, provided it is within agreed scope and does not disrupt production systems. This ensures the assessor can independently verify that vulnerabilities are managed appropriately and controls are functioning as intended.

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.

In MyCSF, when assessors finish reviewing a Requirement Statement and agree with the subscriber’s scoring, they must save their review.

Saving finalizes the assessor’s review, and the Requirement Statement status updates to “Assessor Review Complete.”

This status indicates readiness for QA submission.

Extract Reference (MyCSF Assessor Workflow Guide [0049]):

Requirement Statements are marked “Assessor Review Complete” when the assessor has saved their review and confirmed agreement with the scoring.

In MyCSF, organizational performance dashboards are available under the Analytics tab. This section provides interactive reporting features, including trend charts, compliance scores, domain comparisons, CAP summaries, and benchmarking across multiple assessment objects. Unlike the Reference Library or Administration tab, which are used for framework access and account management, the Analytics tab focuses on reporting and visualization. It allows management and assessors to monitor both single-assessment results and enterprise-wide metrics. Importantly, dashboards are not restricted to certified reports; they are a built-in feature of MyCSF, accessible during preparation, readiness, and validated assessments. This makes the Analytics tab essential for organizations using HITRUST as an ongoing governance and risk management tool.

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.

Regulatory factors are a mandatory part of the scoping process in r2 assessments. These factors represent applicable laws, regulations, or frameworks that impact the organization’s operations. Examples include HIPAA, PCI-DSS, GDPR, state data protection laws, CMS Minimum Security Requirements, and FedRAMP. When a regulatory factor is selected in MyCSF, additional requirement statements are automatically generated within the assessment object. These statements tailor the control environment to match external obligations, ensuring alignment with compliance expectations.

For example, selecting PCI-DSS will add specific controls related to cardholder data protection. Selecting HIPAA will add requirements for safeguarding protected health information. Without selecting these factors, the assessment would not provide complete coverage, and certification would lack credibility. This dynamic tailoring is one of the strengths of HITRUST’s risk-based approach, ensuring each entity’s assessment is relevant to its regulatory landscape.

MyCSF Analytics is a feature that allows organizations to create dashboards, charts, and reports from their assessment data. Analytics can be applied within a single assessment object to track scoring, evidence linkage, CAPs, and requirement coverage. Additionally, analytics can be applied across multiple assessments (e.g., e1, i1, and r2 objects) within the same subscriber organization. This cross-assessment capability is especially valuable for large enterprises performing multiple assessments for different business units or regulatory drivers. It enables comparisons, benchmarking, and enterprise-wide risk visibility. The analytics feature enhances MyCSF’s role as not only an assessment tool but also a continuous risk management platform, giving organizations insight into trends and performance over time.

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.

Control Objectives within the HITRUST CSF describe the intended outcomes that organizations should achieve through the implementation of controls. They do not prescribe how to achieve the result but set the goal or purpose of control activities. For example, a control objective may state that access to systems should be restricted to authorized users. The actual requirement statements beneath that objective describe specific policies, procedures, and technical measures needed to fulfill it. This layered approach aligns with best practices in frameworks like ISO 27001 and NIST, where control objectives serve as high-level goals, and control activities provide the actionable detail. The objective-driven design helps organizations understand not only the “what” but also the “why” behind each control.

The HITRUST CSF v11 introduced a traversable requirement statement portfolio, allowing organizations and assessors to navigate requirements across versions more effectively. This capability ensures consistency, historical traceability, and clarity when mapping requirement statements between CSF iterations. Earlier versions (v9.2, v9.4, v9.6.1) did not support the full traversable portfolio functionality.

Extract Reference (HITRUST CSF v11, CCSFP Study Guide):

Version 11 introduced structural updates including a traversable portfolio of requirement statements, enabling easier mapping and navigation across framework versions for consistent assessments.

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.

Systematic/Interval sampling is a recognized statistical methodology where items are selected at regular intervals from an ordered population. For example, selecting every 100th transaction, log entry, or user account from a file. This approach provides coverage across the dataset while being more efficient than random sampling. HITRUST accepts systematic sampling as long as the population is not ordered in a way that introduces bias (e.g., chronological logs where every 100th entry might reflect similar conditions). By contrast, random sampling requires a truly random number generator, judgmental relies on assessor discretion, and haphazard lacks any structured methodology. For this scenario, selecting every 100th item is clearly Systematic/Interval sampling.

HITRUST requires that all new r2 assessments use the latest available version of the CSF framework. This ensures that assessments reflect the most current regulatory mappings, authoritative source updates, and industry security practices. For example, if HITRUST releases CSF version 11.x, new assessments initiated after its release must adopt that version. Organizations with ongoing assessments may complete them on the prior version but must transition to the latest version for new engagements. This policy ensures consistency and prevents outdated control sets from being used in certification, which could weaken reliance by stakeholders. Keeping assessments aligned with the current version also reflects HITRUST’s commitment to maintaining the CSF as a “living framework.”

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.