CCSFP Questions and Answers

In ani1 assessment, scoring follows a pass/fail logic tied to CAP requirements. If aControl Referencescores below the defined threshold (typically83for i1 assessments), any gaps within its requirement statements must be addressed with arequired Corrective Action Plan (CAP). A score of62is 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 arequired CAP.

In ani1 assessment, scoring below threshold levels (generally83 for certification-critical controls) results in arequired Corrective Action Plan (CAP). A score of37falls into the “Somewhat Compliant” category and indicates major deficiencies. Because i1 assessments emphasize cybersecurity hygiene, HITRUST does not allow “risk acceptance” at such low scores. Instead, CAPs are required to ensure remediation is planned and tracked. This approach guarantees that organizations address weaknesses that could leave them vulnerable to common threats. Unlike r2 assessments, where some flexibility exists based on risk tailoring, i1 is structured to enforce mandatory remediation for below-threshold results. Therefore, a Control Reference score of 37 in i1 unequivocally requires a CAP.

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

Ther2 Validated Assessmentprovides thehighest level of assurancewithin the HITRUST portfolio. It includes all 19 CSF domains and applies a risk-based approach tailored to the organization’s industry, regulatory obligations, and technical environment. The r2 incorporates maturity level scoring (Policy, Procedure, Implementation, Measured, and Managed), allowing stakeholders to evaluate both control presence and long-term sustainability. It is also the only assessment type eligible for atwo-year certification, provided interim requirements are met. By contrast, i1 and e1 assessments provide lower levels of assurance, designed for cybersecurity hygiene and medium-level assurance, respectively. Organizations with complex environments, sensitive data, or high regulatory expectations generally pursue r2 to provide maximum assurance to stakeholders.

The HITRUST CSF scoring rubric evaluates maturity across five levels: Policy, Procedure, Implemented, Measured, and Managed. To achieve certification in an r2 assessment, each domain must meet aminimum aggregate threshold of 71. Full compliance in Policy, Procedure, and Implementation (100% each) results in high scores that exceed the certification threshold. The Measured and Managed levels, while valuable for demonstrating monitoring and governance, are not required to be scored above zero to achieve certification. In this scenario, the organization demonstrates complete documentation and implementation of controls, which satisfies HITRUST’s certification criteria. Therefore, even with Measured and Managed at zero, the assessment can achieve certification because the foundational maturity levels provide sufficient assurance.

HITRUST applies the CAP requirement at theControl Reference level. A CAP is required when the Control Reference score falls at70 or belowand Implementation maturity is not at 100%. In this case, the aggregate score is72.5, 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.

The HITRUSTe1andi1assessments are streamlined, moderate-effort assurance models designed to evaluate an entity’s implementation ofessential 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.

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.

When relying onthird-party reports(such as SOC 2 reports) to satisfy HITRUST requirements, only reports with sufficient detail can be used. HITRUST requires:

A cleardescription of scope(A) to confirm applicability to the assessed environment.

Alist 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 anexecutive summarymay 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.

The HITRUST CSF integrates requirements from multiple authoritative sources (e.g., HIPAA, NIST 800-53, ISO 27001, PCI-DSS). However, the CSF does not replicateall requirements verbatimfrom each framework. Instead, HITRUST rationalizes, harmonizes, and normalizes these sources into asingle 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.

HITRUST allows grouping of components to improve efficiency in assessments, but only when there is sufficienthomogeneityamong the components. Grouping is permitted when systems share the sameconfigurations(e.g., identical firewall rule sets, server builds), the samepatch levels(demonstrating equal maintenance and security posture), or whenfacilities use identical access management systems(ensuring consistent physical security practices). The logic behind grouping is that if controls are identical across multiple assets, then one test can represent the whole group without introducing risk. However, grouping must be supported by documentation proving uniformity. If variations exist—for example, one system with different access rules or a facility with a different badge system—those components must be assessed separately. Grouping reduces duplication and workload, but it requires strict evidence of control uniformity to maintain assessment reliability.

Scoring in HITRUST follows aroll-up model. Requirement Statements are scored at the most granular level. These scores are then averaged to determine the score of theControl Reference. Once all control references within a domain are scored, their averages are rolled up to calculate theDomain Score. Domain scores are critical because HITRUST requires each domain in an r2 assessment to achieve at least a71to qualify for certification. This hierarchical scoring ensures that weaknesses in individual controls impact the higher-level domain score, maintaining balance across domains. Without averaging, entities could potentially offset poor control performance in one area with excellence in another, which would distort the overall risk picture.

HITRUST does not mandate that all required CAPs be remediated within a strictsix-month deadline. Instead, CAPs must include arealistic remediation planwith target dates, owners, and milestones. Some CAPs may be resolved quickly, while others (such as large-scale encryption rollouts) may take longer. HITRUST requires that CAPs are tracked and updated until completion, and progress is reviewed at interim assessments. While assessors may encourage timely remediation (often aiming for six months where feasible), HITRUST does not impose a universal time limit. What matters is that CAPs are properly documented, tracked, and eventually closed. Therefore, the statement that all required CAPs must be remediated within six months isFalse.

HITRUST does not issue certifications limited solely toprivacy-related requirements. While privacy is a critical part of the CSF—reflected in domains such asData Protection & Privacy—HITRUST certifications require coverage ofall 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.”

Validated assessments undergo QA by HITRUST after submission by the assessor. The outcome can be either:

AValidated Report– issued if the assessment is complete but certification thresholds (e.g., domain scores ≥71 for r2) are not met. This report still provides assurance to relying parties by confirming independent validation, even without certification.

AValidated Report with Certification– issued when all certification criteria are met, including minimum domain scores and interim assessment requirements for multi-year validity.

This distinction allows HITRUST to provide value even to organizations that fall short of certification, by documenting their current control maturity and gaps. Organizations can use the validated report as a roadmap to remediate deficiencies and pursue certification in the future.

Unlike validated assessments,Readiness Assessmentscan be performed without a paidMyCSF 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 isnot mandatoryfor readiness. This ensures that even smaller organizations or first-time users can access HITRUST readiness services without financial barriers.

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.

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 theregulatory and organizational factorsselected during scoping. For instance, adding PCI-DSS or HIPAA will increase requirement counts across all types. All assessment types also require testing ofimplementation, since evidence of operational control performance is mandatory for validation. The incorrect option is C: r2 assessments always include all19 domains, and so do e1 and i1 assessments. What differs is the number of requirement statements in each domain, not the domains themselves.

When a requirement statement is marked as Not Applicable (N/A) in MyCSF, HITRUST requires the organization to provide a justification. This justification must be entered into the Subscriber Comments field. The rationale explains why the requirement does not apply to the entity’s environment, systems, or data. For example, if a requirement relates to payment card data but the organization does not process credit cards, the Subscriber Comments field should document that no PCI-DSS scope exists. HITRUST QA reviews these justifications to ensure N/As are applied appropriately. Failure to document rationale can result in QA findings or required CAPs. This requirement preserves transparency and prevents misuse of the N/A designation to exclude applicable controls.

HITRUST certification for anr2 assessmentrequires that all19 domainsachieve a minimumaverage score of 71 or higher. Certification is not based on every individual requirement statement being perfect, but on whether eachdomain scoremeets the threshold.

Looking at theData Protection & Privacy domainin the table:

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

These average to60.75, which is below the 71 threshold.

If the “Privacy Officer” requirement score increases from42 → 50, the recalculated domain average becomes:

(50 + 63 + 68 + 70) ÷ 4 =62.75.

Now consider the rest of the chart:Information Programscores are in the 70s and 80s,Endpoint Protectionis 62 and 79,Wireless Protectionis 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 wouldachieve certificationwith this change, making the correct answerTrue.

During an interim assessment for r2 certifications, only asubset of Requirement Statementsis retested. This sample is not determined manually by assessors or clients but issystematically generated by MyCSF. The tool ensures randomness and fairness while including mandatory items such as:

Requirement Statements with open gapsfrom the prior validated assessment.

Requirement Statements with active Corrective Action Plans (CAPs).

A random selection of additional requirements to confirm continued control performance.

This approach balances efficiency and assurance. It ensures that areas of previously identified weakness are re-examined while still sampling across the broader control set. By automating sample selection, HITRUST prevents bias and ensures consistency across interim reviews.

MyCSF Analyticsis a feature that allows organizations to create dashboards, charts, and reports from their assessment data. Analytics can be appliedwithin a single assessment objectto track scoring, evidence linkage, CAPs, and requirement coverage. Additionally, analytics can be appliedacross 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 acontinuous risk management platform, giving organizations insight into trends and performance over time.

PCI-DSSis not considered aRisk Management Framework (RMF). Instead, it is aprescriptive security standarddeveloped 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 asNIST RMFor 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.

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 includeHIPAA, PCI-DSS, GDPR, state data protection laws, CMS Minimum Security Requirements, and FedRAMP. When a regulatory factor is selected in MyCSF, additionalrequirement statementsare 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.

HITRUST requires thatall assessorsworking on validated assessments be affiliated with an approved External Assessor organization, and each engagement must havea CCSFP-certified resource involved. However, there isno formal percentage requirementdictating 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.