HITRUST CCSFP - Certified CSF Practitioner 2025 Exam

In an r2 assessment, CAP requirements are determined at the Control Reference level. If the aggregate score falls below the certification threshold of 71, and the Implementation maturity level is not at 100%, a Corrective Action Plan (CAP) must be documented. This ensures that organizations commit to remediating critical control deficiencies before certification can be finalized. CAPs must include clear details such as responsible parties, remediation steps, and timelines. Without CAPs, HITRUST will not accept the assessment for certification. Even if Policy or Procedure scores are strong, missing implementation creates unacceptable risk. Therefore, HITRUST mandates CAPs in these cases to close certification-critical gaps.

The responsibility for defining the scope of an assessment lies with client management. The organization undergoing the assessment must identify which systems, applications, facilities, and business units are in scope. This decision is based on business objectives, regulatory requirements, contractual obligations, and the sensitivity of data being processed. External Assessors play a supporting role by reviewing scope decisions and ensuring they are reasonable and sufficient to meet assurance objectives. HITRUST does not define scope directly but requires that scope decisions be documented and defensible. An accurately defined scope ensures that the assessment reflects the organization’s risk exposure without omitting critical components. Mis-scoping can either undermine assurance or create unnecessary testing burden.

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.

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.

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.

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.

HITRUST requires that each of the 19 domains achieve a minimum score of 71 for an organization to qualify for r2 certification. This threshold ensures that entities maintain a consistent level of maturity across all control areas, rather than excelling in some while neglecting others. The 71 threshold is calculated from the weighted average of requirement statements within a domain, factoring in Policy, Procedure, and Implementation maturity scores (with Measured and Managed as applicable). If any domain falls below 71, the assessment may still produce a validated report, but it will not result in certification. This strict requirement highlights HITRUST’s emphasis on balanced coverage across all areas of security and privacy.

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.

HITRUST distinguishes between grouped and ungrouped components. When primary components (e.g., servers, databases, firewalls) are not grouped, they must be tested individually. This is because each ungrouped component may have unique configurations, operational practices, or control implementations, meaning sampling would not yield accurate results. Sampling is only permitted when components are grouped and proven to be functionally identical. In ungrouped situations, the assessor must test each component to validate control effectiveness. This ensures accuracy in scoring and avoids the risk of overlooking control failures in heterogeneous environments. Therefore, when components remain ungrouped, the assessor is required to test all components within scope and cannot rely on sampling methods.

The A1 Security Assessment module evaluates the security, governance, and risk management of artificial intelligence models. HITRUST specifies coverage for widely used model types, including:

Predictive models, which forecast outcomes based on historical data (e.g., fraud detection, patient risk scoring).

Generative models, which create new data outputs (e.g., AI image or text generators).

Rule-based models, which use defined logic for decision-making.

The goal of the A1 assessment is to ensure that these AI models are developed, implemented, and monitored securely, with appropriate safeguards around data integrity, bias management, and model explainability. Options like Hodgkin-Huxley (a neuroscience model) and Back Propagation (a training algorithm) are not types of AI models scoped by the A1 assessment. Instead, the A1 factor focuses on applied model categories used in operational environments.