CCSFP Certified CSF Practitioner 2025 Exam Questions and Answers

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.”

For r2 certifications, HITRUST requires an interim assessment at the one-year mark to ensure ongoing compliance. The MyCSF platform automatically generates the interim assessment object 90 days prior to the certification anniversary date. This gives organizations and assessors adequate time to prepare, perform testing, and submit the interim assessment before the deadline. The auto-creation ensures that no certified entity misses the requirement, as failure to complete the interim would result in certification lapse. The 90-day window balances preparation time with the need for timeliness, ensuring continuous assurance between the initial validated assessment and the two-year certification cycle.

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.

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.

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 is structured around a hierarchical model:

Control Categories → 14 high-level groupings (e.g., Access Control, Incident Management).

Control Objectives → Define goals under each category.

Control References → Specific implementation requirements aligned to objectives.

This structure ensures traceability from high-level objectives down to actionable control requirements.

Option B describes NIST Cybersecurity Framework (CSF), not HITRUST.

Option A/C include COBIT, which is integrated but not the structural foundation.

Extract Reference (HITRUST CSF Overview, CCSFP Guide [0134]):

The CSF is organized into Control Categories, Control Objectives, and Control References.

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.

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 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.

Certification requires all Requirement Statements to meet the 62.5% threshold.

From the chart:

“The Privacy Officer...” scored 42, below 62.5.

“Antivirus clients have...” scored 62, also below 62.5.

Because there are Requirement Statements below threshold, the assessment will contain Required CAPs, and certification cannot be awarded until remediation.

Extract Reference (HITRUST CSF Scoring Methodology [0192]):

Certification requires all Requirement Statements to meet the minimum scoring threshold; scores below 62.5 prevent certification.

When 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.

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.

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.

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.

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.

The Interim Assessment (required at the 1-year mark during a 2-year r2 Certification period) ensures continued compliance. It does not retest all Requirement Statements from the initial assessment. Instead, it involves:

Testing all CAPs from the original validated assessment.

Confirming no significant changes occurred in the in-scope environment.

Testing a random sampling of Requirement Statements, as chosen by the MyCSF tool, to confirm continued adherence.

Completing assessor assertions to verify compliance status.

Extract Reference (CCSFP Study Guide, Interim Assessment Requirements [0046]):

Interim Assessments focus on testing CAPs, environmental change confirmation, assessor assertions, and a sample of Requirement Statements; full retesting of all controls is not required.

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.

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.

The Measured maturity level evaluates whether organizations actively monitor the effectiveness of controls. HITRUST defines seven criteria for Measured, including metrics, data collection, analysis, reporting, and corrective action tracking. If these seven criteria are fully met, scoring can begin at Tier 4 strength, reflecting a mature measurement process. In the example, system administrators are responsible for measuring firewall configuration security, and if they meet all seven criteria (such as reviewing firewall rules, analyzing logs, reporting deviations, and initiating remediation), the Measured compliance level can start at Tier 4. The assessor may then adjust scoring based on coverage and frequency, but the baseline is Tier 4 once all criteria are satisfied. This ensures consistent evaluation of advanced maturity levels across controls.

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.

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.

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.

When a relying party requests an Insights Report covering AI risks, the appropriate selection in MyCSF is the A1 Risk Assessment. The A1 Security Assessment adds AI-related requirements to evaluate technical and governance safeguards for artificial intelligence systems. However, the A1 Risk Assessment is specifically designed to generate Insights Reports that highlight AI-related risk exposures, model governance practices, and data usage concerns. HITRUST distinguishes between these two factors to ensure organizations scope their assessment appropriately. By selecting the A1 Risk Assessment, the assessment object will include additional requirement statements aligned with AI risks, enabling the Insights Report output. This ensures stakeholders receive the necessary assurance information about the organization’s risk environment in relation to AI.

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.

Secondary scoping components in HITRUST are environmental or supporting elements that contribute to how primary components are protected. For the requirement related to secure destruction of sensitive media, an appropriate secondary scoping component would be shred bins. Shred bins represent the physical mechanism through which media or documents containing sensitive information are collected and securely destroyed. They directly support the requirement for secure media destruction methods. Fire extinguishers, fire bags, trash cans, or storage boxes do not directly relate to this requirement, as they address other aspects of physical safety or storage rather than secure destruction. Including shred bins ensures that physical controls are properly validated as part of secure media disposal processes, aligning with HITRUST’s risk-based approach to protecting sensitive data.

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.

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.

In HITRUST assessments, certain maturity level scores may be pre-populated in MyCSF based on scoping factors, inheritance, or framework defaults. However, these default entries are not locked and can be changed by the assessed entity or assessor if evidence supports a different result. For example, if a requirement defaults to “Non-Compliant (0),” but the organization provides documentation showing a control is fully in place, the score may be updated to reflect “Fully Compliant (100).” Similarly, inherited scores from a service provider can be overridden if the organization chooses not to rely on inheritance. HITRUST’s design encourages entities to evaluate each control in their environment rather than accepting defaults blindly. QA will review all adjusted scores against supporting evidence to confirm accuracy.

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.

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

The 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.

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.

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.

HITRUST certifications apply to implemented systems and environments, not products, individuals, or facilities. For example, a healthcare provider may certify its electronic health record (EHR) platform, data center, and IT operations supporting PHI. HITRUST does not certify products like software applications sold to customers; instead, it certifies how organizations implement and operate them securely. Similarly, while HITRUST offers professional credentials like CCSFP or CHQP for people, these are certifications of knowledge, not organizational assurance. Facilities are included in assessments as scoping components but are not independently certified. The certification is always tied to an organization’s operational environment as validated through a CSF assessment.

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.

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.

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.

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.

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.