HITRUST CCSFP Certified CSF Practitioner 2025 Exam Exam Practice Test

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.

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, 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.

For the Measured domain, evidence must exist that controls are being evaluated for effectiveness.

Without documentation, a control cannot be measured, as there is no evidence of monitoring or review activity.

Documentation is the basis for determining repeatability, maturity, and strength in the scoring model.

Extract Reference (HITRUST Scoring Methodology [0126]):

If a control is undocumented, it cannot be evaluated in the Measured domain, as measurement requires documentation of monitoring.

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.

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.

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.

Certification requires:

Each Requirement Statement score ≥ 62.5% to avoid a CAP.

In this table, at least one Requirement Statement scores below 62.5:

Privacy Officer... = 42

Antivirus clients have... = 62 (slightly below threshold).

Because one or more required Requirement Statements fall below 62.5, this triggers Required CAPs.

Extract Reference (HITRUST CSF Assurance Scoring Guidance [0193]):

Any Requirement Statement scoring below 62.5 requires a CAP; therefore, this assessment would contain at least one Required CAP.

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.

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.

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.

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.

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).

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.

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.

The HITRUST CSF is designed to protect all forms of sensitive information, not just structured digital data. This includes words (text documents, records), numbers (financial data, identifiers), pictures (images, radiology scans, photographs), and sounds (voice recordings, call center data). The comprehensive scope ensures that entities consider every medium in which sensitive information may exist, whether electronic, physical, or spoken. This aligns with regulatory definitions, such as HIPAA, which recognizes both electronic and non-electronic forms of protected health information. By covering all forms, HITRUST ensures organizations apply consistent safeguards across their environments and do not overlook exposures outside IT systems, such as printed reports or recorded conversations.

When performing HITRUST scoping, organizations must include regulatory factors relevant to their operational and geographic context. Since this entity operates in Massachusetts and Nevada, two state-specific privacy and security laws apply:

Massachusetts Data Protection Act (201 CMR 17.00): Requires businesses handling personal data of Massachusetts residents to maintain a written information security program (WISP), including encryption and monitoring controls.

Nevada Security of Personal Information Law (NRS 603A): Mandates encryption for personal information stored or transmitted electronically and requires reasonable security measures.

The CMS Minimum Security Requirements (High) (B) would apply only if the entity processes Medicare/Medicaid-related data. The Texas Health and Safety Code (D) applies only to Texas-based covered entities. Subject to De-ID Requirements (E) is a general data-handling condition, not a state-specific regulatory factor.

Therefore, only Massachusetts Data Protection Act and Nevada Security of Personal Information Requirements apply in this scenario.

In the HITRUST MyCSF environment, organizations may define multiple assessment objects. An assessment object refers to the specific environment, business unit, or system being evaluated under a HITRUST assessment. This allows organizations with diverse operations or multiple systems to scope and manage assessments separately, ensuring accurate applicability of requirement statements.

Extract Reference (CCSFP Study Guide & HITRUST CSF Guidance, [0090]):

Organizations may establish multiple assessment objects in MyCSF to represent different systems, applications, or environments subject to CSF assessment.

Thus, the correct response is True

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.

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.

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.

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.

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.

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.

For Policy and Procedure maturity levels, HITRUST requires a minimum of 30 days between creation or updates and reconsideration for testing in an r2 assessment. This ensures that the policies and procedures are not just newly drafted but have been approved, communicated, and adopted within the organization. Thirty days allows time for staff awareness, training, and initial application, which HITRUST views as necessary evidence of operationalization. Unlike Implementation maturity (which requires 90 days of operational evidence for reconsideration), documentation-based maturity levels require a shorter validation window. This distinction reflects the difference between proving written governance documents exist versus proving operational controls function consistently.

When an organization marks a requirement statement as Not Applicable (N/A) in an assessment, it is mandatory to provide a clear rationale in the Subscriber’s Comments field. This ensures transparency for both external assessors and HITRUST reviewers, demonstrating why the requirement does not apply to the environment or assessment object.

Without a justification, the N/A designation would be incomplete.

Assessors rely on this rationale to validate scope appropriateness.

Extract Reference (HITRUST CSF Assessment Guidance, [0048]):

For requirement statements marked as N/A, the Subscriber’s Comments field must include sufficient rationale explaining the inapplicability of the requirement.

Correct response: True.

Technical risk factors in HITRUST scoping include elements that influence the size and complexity of the IT environment. Examples are Number of Users (reflecting identity management challenges), Number of Transactions (indicating workload and exposure volume), and Accessible from the Internet (highlighting attack surface considerations). These factors affect how many requirement statements are assigned and the level of implementation required. However, Number of Facilities is not considered a technical factor. Instead, facilities are categorized under Organizational or Operational risk factors, since they represent physical locations and operational complexity rather than technical characteristics. This distinction ensures risk tailoring addresses both IT-centric and business-environment dimensions separately.

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.

HITRUST accommodates organizations that cannot upload sensitive evidence to the MyCSF portal due to corporate or regulatory policies. The mechanism for this is QA Tasks. Through QA Tasks, HITRUST QA reviewers can request clarifications, additional evidence, or narrative responses, which can be provided without uploading sensitive raw data. This method allows entities to describe processes, reference documents, or provide redacted information while maintaining compliance with their internal data-handling policies. Options such as “Live QA” or “Onsite visits” are not part of the standard assurance program workflow. Escalated QA refers to dispute resolution or additional reviews and does not address evidence handling. QA Tasks are the standard method HITRUST uses to facilitate communication and evidence review without violating data-handling restrictions.

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.

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.

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.

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]

In HITRUST MyCSF, inheritance allows organizations to leverage control implementations from other entities or internal departments to reduce redundancy and streamline assessments.

Cross Organizational inheritance → Accepted, allows borrowing controls from a trusted external organization (e.g., cloud provider).

Internal inheritance → Accepted, allows reuse of controls across internal business units or shared services.

External inheritance → Accepted, typically when outsourcing to a vendor that provides evidence.

Bi-lateral inheritance → Not recognized by HITRUST, as inheritance flows one way only (from provider to relying party).

Extract Reference (HITRUST MyCSF User Guide, CCSFP Program Objectives):

Appropriate inheritance types include cross organizational, internal, and external. Bi-lateral inheritance is not supported in MyCSF, as inheritance is directional and validated only from provider to consumer.

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.

An r2 certification is valid for two years, but only if an interim assessment is performed at the one-year mark and interim requirements are met. The interim assessment ensures that the organization continues to maintain its controls, remediate CAPs, and discharge any pending N/A justifications. If an interim is not completed or requirements are not met, the certification can lapse. Unlike option A, remediation of all CAPs and N/As is not required before certification is maintained, though CAP progress must be monitored. Certification is not automatically valid for two years (option C), nor is it indefinite (option D). Thus, the correct answer is that certification is valid for two years provided interim requirements are met.

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.

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.

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.

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 requires that all assessors working on validated assessments be affiliated with an approved External Assessor organization, and each engagement must have a CCSFP-certified resource involved. However, there is no formal percentage requirement dictating how many hours must be performed by a CCSFP. Instead, HITRUST mandates that CCSFP professionals oversee, guide, and ensure proper application of the CSF methodology. Junior or non-certified staff may assist with evidence gathering, documentation, or technical testing under supervision. Ultimately, CCSFP-certified individuals are accountable for quality and methodology adherence, but HITRUST allows assessor firms flexibility in resourcing. The absence of a percentage standard accommodates varying project sizes and team compositions.

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.