CCSFP Certified CSF Practitioner 2025 Exam Questions and Answers

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:

Assessors must maintain independence and avoid conflicts of interest.

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

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

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

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

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.

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 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]

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 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.

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.

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.

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 allows organizations to inherit scores from third-party providers (such as cloud service providers) when those providers have already completed validated HITRUST assessments. For inheritance to be valid, three conditions must be met:

The Cross Version IDs (CVIDs) must match between the requirement statement in the provider’s assessment and the subscriber’s assessment to ensure alignment across framework versions.

The requirement must be designated as inheritable by HITRUST; not all requirements are eligible for inheritance.

The provider must have published their assessment for inheritance in MyCSF, enabling subscribers to formally link and inherit the validated results.

If any of these are missing, inheritance cannot occur. This ensures transparency, consistency, and proper traceability between assessments.

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.

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

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.

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

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.

Primary scoping components are systems, applications, and infrastructure directly involved in processing, storing, or transmitting sensitive information. Examples include hypervisors (supporting virtualized systems), servers (hosting applications and data), databases like Oracle (storing structured data), and network attached storage (NAS) devices (storing files). These are all core elements of an IT environment subject to assessment. By contrast, smoke detectors are physical safety devices, not considered primary scoping components for HITRUST. Physical safeguards like detectors may fall under facility security, but they are not tested as primary IT components. Proper identification of primary scoping components is critical to defining the assessment boundary and ensuring appropriate requirements are applied.

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 HITRUST CSF integrates requirements from multiple authoritative sources (e.g., HIPAA, NIST 800-53, ISO 27001, PCI-DSS). However, the CSF does not replicate all requirements verbatim from each framework. Instead, HITRUST rationalizes, harmonizes, and normalizes these sources into a single unified framework. This means that overlapping requirements across standards are consolidated into common control references, reducing redundancy. Additionally, not every provision from an authoritative source is represented; instead, HITRUST includes requirements that are most relevant to information protection and compliance assurance. For example, PCI-DSS operational practices like business rules may not appear exactly as written, but their security objectives are captured within CSF control statements. Therefore, the CSF is comprehensive and risk-based, but it does not literally encompass every requirement word-for-word.

When scoring Measured and Managed maturity levels in HITRUST, evidence requirements are more rigorous. If these levels are scored above 50%, organizations must demonstrate that formal processes exist to measure control performance, that reports are generated to monitor effectiveness, and that accountability for measurement and management is assigned. Specifically:

Processes show how control gaps are tracked, risks mitigated, and remediation addressed.

Reports provide tangible outputs proving monitoring activities (e.g., audit logs, vulnerability reports).

Responsible individuals must be identified to show governance and ownership of measurement functions.

Organizational scoping factors, while important for tailoring requirements, do not serve as evidence of maturity scoring. HITRUST’s QA team requires this documentation to confirm that high maturity levels are not claimed without demonstrable evidence of ongoing monitoring and governance.

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.

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

HITRUST 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.

Comprehensive and Detailed Explanation:

Organizations may create multiple assessment objects to reflect differences across:

Business units (e.g., one unit may be healthcare, another financial).

Platforms or systems that present unique risks.

Control applicability, where relevant controls differ due to scope or environment.

Using multiple objects enables tailored assessments that align to organizational risk and compliance needs.

Extract Reference (HITRUST MyCSF Guidance [0175]):

Organizations may define multiple assessment objects when security requirements, risks, or applicable controls differ across units or systems.

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 External Assessors to reserve QA slots prior to submitting validated assessments. This ensures QA capacity is available and assessments are reviewed in a timely manner. However, the guidance does not specify a strict six-month minimum reservation period. Instead, HITRUST recommends assessors reserve QA slots well in advance of their submission target date, based on the anticipated complexity and workload. In practice, reservations may often be made months in advance, but there is no formal rule mandating six months. The flexibility allows assessors to adjust their schedules while ensuring HITRUST can properly plan QA resources. As such, the statement that reservations must always be made six months ahead is False.

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.

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 HITRUST, scoring follows a hierarchical roll-up process. At the lowest level, Requirement Statements are scored across the five maturity levels: Policy, Procedure, Implemented, Measured, and Managed. These individual requirement scores are then aggregated to produce the Control Reference score. Control Reference scores are averaged to determine the Domain score, and finally, domain scores are used to determine whether certification thresholds are met. Each level of scoring influences the next, meaning deficiencies at the Requirement Statement level impact the higher-level domain performance. This structure ensures that assessments provide a balanced and transparent picture of organizational control effectiveness. No single requirement is hidden; its performance is reflected in the domain-level scoring. Since r2 certifications require each of the 19 domains to score at least 71, accuracy in Requirement Statement scoring is critical.

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.

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.

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.

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 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.”

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.

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.

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.

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.

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.