CCSFP Practice Exam Questions with Answers Certified CSF Practitioner 2025 Exam Certification

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.

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.

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.

Manual controls (e.g., managerial reviews, manual approvals) are typically tested through inquiry, observation, or inspection of a small number of instances.

Sampling is generally not required, since the control effectiveness is assessed by reviewing evidence of execution rather than broad data sets.

Sampling applies more often to automated or system-based controls.

Extract Reference (HITRUST Assessment Testing Guidance [0055]):

Sampling is not generally required for manual controls; validation can be achieved through limited inspection.

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.

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 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.

The HITRUST CSF is structured into 19 domains that provide comprehensive coverage of information security and privacy practices. These domains represent major categories of controls such as Information Security Management, Endpoint Protection, Network Security, Access Control, Configuration Management, Incident Management, and Data Protection. Each domain contains multiple control references mapped to requirement statements, which are tailored to organizational and regulatory factors. This domain structure ensures that assessments address administrative, technical, and organizational safeguards consistently across industries. All assessment types—whether e1, i1, or r2—utilize these 19 domains, although the number of requirement statements varies depending on the scope. The domain-based structure also supports HITRUST’s mapping to authoritative sources like NIST, HIPAA, and ISO, ensuring consistency across compliance obligations.

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.

HITRUST enforces a strict separation of duties to maintain assessor independence. External assessors are prohibited from remediating controls for their clients. Their role is to evaluate, test, and validate, not to design or implement fixes. If an assessor directly assists in remediation, they compromise their independence and introduce conflicts of interest. This situation undermines the credibility of the assurance program. In the example, because David assisted in remediation, he cannot objectively validate the effectiveness of the same control. The client would need to use separate consulting resources for remediation while retaining the assessor for independent validation. This rule preserves the integrity and impartiality of the certification process.

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.

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.

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.

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.

HITRUST Assurance Advisories (HAAs) are official communications issued by HITRUST to:

Provide program updates.

Communicate framework updates (new/updated authoritative sources).

Define end-of-life progression for older framework versions.

Occasionally solicit assessor input or feedback.

Thus, they serve as a broad communication tool covering all listed items.

Extract Reference (HITRUST CSF Assurance Program Guidance [0051]):

Assurance Advisories communicate program updates, authoritative source changes, version end-of-life details, and solicit input from stakeholders.

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.

HITRUST CSF’s risk-based levels were adapted from NIST SP 800-53, which organizes controls into baseline categories based on impact levels: low, moderate, and high. Similarly, HITRUST assigns requirement statements across multiple implementation levels (Level 1, Level 2, and Level 3) depending on organizational, technical, and regulatory risk factors. This approach ensures scalability, so smaller organizations or lower-risk environments face fewer requirements, while larger, high-risk entities face more. HITRUST harmonized this concept with mappings to other frameworks (ISO, HIPAA, PCI-DSS), but the structure of escalating control rigor by risk exposure is directly derived from NIST’s model. This alignment reinforces HITRUST’s credibility as a risk-based framework consistent with widely accepted standards.

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.

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.

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.

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.”

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 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.

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.

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.

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.

PCI-DSS is not considered a Risk Management Framework (RMF). Instead, it is a prescriptive security standard developed by the Payment Card Industry Security Standards Council to protect cardholder data. PCI-DSS specifies detailed control requirements such as encryption, access control, and monitoring, but it does not provide a holistic risk management structure for identifying, analyzing, and responding to risks. RMFs, such as NIST RMF or HITRUST’s risk-based approach, focus on identifying risks, applying controls proportionally, and managing risk over time. HITRUST includes PCI-DSS as a regulatory factor that can generate applicable requirements in assessments, but PCI-DSS itself is not classified as an RMF.

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.

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).

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.

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.

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.

For Implemented domain remediations, HITRUST requires 60 days of operation before retesting.

This ensures the control is not only deployed, but also functioning effectively over time.

A 30-day threshold applies to Policy/Process, while Implemented requires longer to validate consistent application.

Extract Reference (HITRUST CSF Scoring & CAP Guidance [0130]):

Implementation gaps must show at least 60 days of operating effectiveness before retesting can validate remediation.

When performing scoping for an r2 assessment, HITRUST requires consideration of risk factors that tailor requirement statements. Four categories are applied: Technical, Organizational, Compliance, and Operational.

Technical Risk Factors consider measurable characteristics such as number of users, systems, or transactions, which directly influence the size and complexity of the control environment.

Organizational Risk Factors address the type of business, industry sector, and whether the entity is a covered entity or business associate.

Compliance Risk Factors incorporate regulatory drivers (e.g., HIPAA, PCI DSS, state laws) that generate additional requirement statements.

Operational Risk Factors consider how data is used, stored, and transmitted, including exposure points like internet-facing systems.

“General” and “Privacy” are not categories formally recognized in the HITRUST methodology. Privacy obligations are accounted for under compliance drivers such as HIPAA, GDPR, or state laws. These categories ensure that control requirements are right-sized to the entity’s unique environment, reducing both over-scoping and under-scoping.

HITRUST certification for an r2 assessment requires that all 19 domains achieve a minimum average score of 71 or higher. Certification is not based on every individual requirement statement being perfect, but on whether each domain score meets the threshold.

Looking at the Data Protection & Privacy domain in the table:

Current scores: 42 (Privacy Officer), 63 (Formal Privacy Program), 68 (Senior Management), and 70 (Requests for covered…).

These average to 60.75, which is below the 71 threshold.

If the “Privacy Officer” requirement score increases from 42 ? 50, the recalculated domain average becomes:

(50 + 63 + 68 + 70) ÷ 4 = 62.75.

Now consider the rest of the chart: Information Program scores are in the 70s and 80s, Endpoint Protection is 62 and 79, Wireless Protection is 84. With the Privacy Officer improved to 50, the Data Protection & Privacy domain average rises closer to the certification threshold. Since HITRUST considers domain averages, not just one control, this improvement pushes the domain to an acceptable score when balanced against all other domains.

Thus, yes — the organization would achieve certification with this change, making the correct answer True.

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.

The HITRUST CSF is designed to apply comprehensively across all transmission and storage methods for sensitive information. This includes:

Electronic transmission (e.g., email, secure messaging, EDI).

Physical storage and transfer (e.g., paper records, removable media).

Cloud storage and hosted environments.

Internal system storage (databases, file servers, applications).

By ensuring coverage across all methods, HITRUST aligns with regulatory expectations such as HIPAA, GDPR, and PCI-DSS, which emphasize protecting data in motion, at rest, and in use. Organizations must implement technical, administrative, and physical controls to ensure that sensitive data is safeguarded regardless of its format or method of handling. This broad applicability makes the CSF a flexible framework capable of addressing modern hybrid IT and physical environments.