When a requirement statement or control reference fails to meet the HITRUST scoring threshold, a Corrective Action Plan (CAP) may be required. CAPs represent formal remediation commitments that must be documented in the assessment object before submission to QA. Each CAP must include details such as the control deficiency, planned remediation steps, responsible parties, milestones, and expected completion dates. HITRUST QA will verify that all required CAPs are present before accepting the assessment for review. Without CAP documentation, the assessment submission is considered incomplete. This process ensures transparency and accountability and demonstrates to relying parties that the organization has a structured plan to close gaps. Therefore, the statement is True.
[References: HITRUST Assurance Program Requirements – “CAP Documentation”; CCSFP Practitioner Guide – “CAPs and Submission Readiness.”, , , ]
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