CCSFP Questions and Answers

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.

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

The MyCSF document repository is designed to provide efficiency in evidence management. Documents uploaded into the repository can be reused across multiple assessments or assessment objects without the need to upload them again. This helps organizations streamline audit evidence, reduce redundancy, and maintain consistency across different assessment scopes.

Extract Reference (HITRUST MyCSF Guidance, [0113]):

The document repository allows documents to be reused and accessed across multiple assessment objects, thereby improving efficiency in the evidence submission process.

Scoring in HITRUST follows a roll-up model. Requirement Statements are scored at the most granular level. These scores are then averaged to determine the score of the Control Reference. Once all control references within a domain are scored, their averages are rolled up to calculate the Domain Score. Domain scores are critical because HITRUST requires each domain in an r2 assessment to achieve at least a 71 to 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.

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.

Illustrative Procedures are example testing steps provided in HITRUST to help assessors evaluate requirement statements consistently. They are not mandatory, but they serve as a guide for developing tailored testing procedures. Their uses include:

Implementation testing guidance (B): They show assessors what evidence to look for and how to test control performance.

Optional procedures (C): Organizations and assessors may adapt or replace them with equivalent procedures.

Test plan foundation (D): Assessors use them as a starting point to design their own testing plans, ensuring consistency and thoroughness.

Illustrative Procedures are not used for maintaining consistency between the entity and assessor responses (A), since testing must remain objective and independent. Their purpose is to promote consistent evaluation and reduce ambiguity.

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

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.

HITRUST does not mandate that all required CAPs be remediated within a strict six-month deadline. Instead, CAPs must include a realistic remediation plan with 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 is False.

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.

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.

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.

A Readiness Assessment Report is self-assessment–based and prepared with or without an assessor to help organizations identify control gaps.

The highest level of assurance is provided by a Validated Assessment Report, which undergoes external assessor validation and HITRUST quality assurance.

Therefore, a readiness assessment does not provide the highest level of assurance.

Extract Reference (HITRUST Assurance Program Guidance [0019]):

Readiness Assessments help identify gaps but do not provide certification or the highest level of assurance; only validated assessments do.

The scoring model in HITRUST is hierarchical. Each Requirement Statement is scored individually across maturity levels (Policy, Procedure, Implemented, Measured, Managed). These scores roll up into Control References, which represent collections of related requirement statements. The average of Control References within a domain determines the Domain Score. Finally, domain scores are used to evaluate whether certification thresholds are met (e.g., minimum domain score of 71 for r2 certification). This hierarchical averaging ensures that deficiencies in individual requirements are reflected in higher-level scores, promoting balance across all controls within a domain.

HITRUST Assurance Advisories (HAAs) are issued when necessary to communicate important updates, clarifications, or changes impacting the CSF Assurance Program. These advisories are not bound to a fixed schedule (monthly, quarterly, or annually), but rather published as needed.

Extract Reference (HITRUST CSF Assurance Program, CCSFP Content [0167]):

There is no formal schedule for issuing HITRUST Assurance Advisories; they are published on an as-needed basis to communicate relevant updates.

Correct response: There is no formal schedule.

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.

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

The 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.

A validated assessment does not require a readiness assessment as a prerequisite.

A Readiness Assessment is optional and intended to help organizations self-identify gaps before a validated assessment.

A Validated Assessment involves an independent HITRUST Authorized External Assessor validating evidence and submitting results to HITRUST for quality assurance and potential certification.

Many organizations choose to do a readiness assessment first, but it is not mandatory.

Extract Reference (CCSFP Study Guide & HITRUST CSF Assurance Program [0020]):

Organizations may perform a readiness assessment prior to a validated assessment to identify gaps, but it is not required; validated assessments can be performed independently.

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

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.

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 Readiness Assessment is designed to give organizations flexibility when evaluating their security and compliance posture. Unlike validated assessments, which are bound by specific methodologies, thresholds, and QA requirements, the readiness format allows entities to scope assessments more freely. This includes the ability to select any HITRUST authoritative source, such as HIPAA, PCI-DSS, NIST, ISO, or GDPR, for self-assessment purposes. The readiness option is often used for gap analysis, remediation planning, and preparing for a future validated assessment. Since the results are not submitted to HITRUST QA, organizations can tailor the assessment to their needs without external restrictions. Neither e1, i1, nor r2 assessments provide this level of flexibility, as those validated assessments are standardized and tightly controlled.

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.

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 enforces strict evidence requirements to maintain credibility of assessment results. For Policy and Procedure maturity levels, if a score above 25% is claimed, the organization must link appropriate evidence (e.g., documented policies, standard operating procedures). For Implementation, Measured, and Managed, evidence must be provided whenever a score greater than 0% is claimed. This ensures that claims are supported by objective artifacts rather than assertions. Evidence can include policy documents, monitoring reports, logs, meeting minutes, or audit records. HITRUST QA verifies that evidence is linked to requirement statements at each maturity level. Without linked evidence, scores may be reduced or reverted during QA. This policy ensures transparency, accountability, and prevents overstatement of control effectiveness.

The r2 Validated Assessment provides the highest level of assurance within 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 a two-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.

Preview Profile in MyCSF allows organizations to model different scoping scenarios and view how many Requirement Statements would apply.

This can be done without formally updating the assessment object.

“Applicable Controls” and “Preview Changes” are related to finalized objects, while “Create Assessment” launches a new one.

Extract Reference (MyCSF Guidance [0181]):

The Preview Profile feature allows subscribers to compare Requirement Statement counts under different scenarios without committing changes to the assessment object.

Correct response: Preview Profile.

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 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.

Validated assessments, whether e1, i1, or r2, must be conducted by HITRUST-approved External Assessors. These assessors are accredited organizations trained and certified by HITRUST to apply the CSF methodology consistently. Their role is to independently validate the entity’s control environment and testing results. Without an approved assessor, the validated assessment cannot be submitted to HITRUST QA or result in a validated report or certification. Readiness assessments differ, as they may be performed internally by the organization and do not require an external assessor. This requirement ensures independence, objectivity, and quality in the assurance process, protecting the reliability of HITRUST certifications.

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.

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.

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

The HITRUST CSF is not intended to replace existing regulatory frameworks such as HIPAA or security standards like NIST 800-53. Instead, the CSF harmonizes and integrates requirements from these and other authoritative sources into a single certifiable framework. For example, HIPAA Security Rule provisions and NIST 800-53 controls are mapped into the CSF domains and requirement statements. This enables organizations to demonstrate compliance with multiple frameworks through one assessment. However, the CSF does not eliminate or supersede the original obligations. Covered entities must still comply with HIPAA, and federal contractors may still need to align with NIST standards directly. The CSF serves as a consolidated implementation tool, not a legal or regulatory replacement.

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.

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

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

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

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

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

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

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