Pass the HITRUST CSF Practitioner CCSFP Questions and answers with CertsForce

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.

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.

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.

For an r2 Certification:

Certification is valid for two years, but an Interim Assessment must be performed at the 12-month mark to maintain certification status.

This ensures continuous compliance, validation of CAP progress, and confirmation of no significant scope changes.

Extract Reference (HITRUST Assurance Program, CCSFP Guide [0023]):

Interim Assessments are required 12 months after r2 certification to maintain certification validity for the second year.

The r2 assessment is the most risk-tailorable of all HITRUST assessment types. Unlike the standardized e1 and i1 assessments, which are designed for essential or moderate assurance, the r2 adapts dynamically based on organizational, technical, compliance, and operational risk factors. For example, the number of users, systems, or internet-facing components directly impacts the number and type of requirement statements. Regulatory drivers such as HIPAA, PCI-DSS, or GDPR also add requirements, ensuring the assessment aligns with the entity’s unique obligations. This tailoring ensures that organizations with higher risk exposure face more stringent testing, while lower-risk entities are not overburdened with unnecessary controls. Neither interim assessments nor bridge certificates are tailorable—they are point-in-time processes tied to existing validated assessments.

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.

Certification can only be achieved through a Validated Assessment (not readiness).

Eligible assessment types for certification are:

e1 Validated Assessment

i1 Validated Assessment

r2 Validated Assessment

Readiness Assessments, Customized, or Targeted Assessments cannot result in certification.

Extract Reference (HITRUST CSF Assurance Program [0158]):

Only validated e1, i1, or r2 assessments are eligible for HITRUST certification.

HITRUST does not determine scope in disputes between clients and assessors.

The organization (subscriber) ultimately owns responsibility for defining and attesting to the assessment scope.

The External Assessor is responsible for verifying that the defined scope is reasonable, complete, and appropriate.

HITRUST only reviews submitted assessments for quality assurance but does not directly arbitrate scope disagreements.

Extract Reference (HITRUST CSF Assurance Program, CCSFP Guidance [0027]):

Subscribers determine scope; External Assessors validate scope appropriateness. HITRUST does not dictate or resolve scope disputes.

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 requires strict independence within the External Assessor QA process. The Quality Assurance Reviewer must be independent of the engagement team to provide unbiased oversight. This role cannot be performed by the Engagement Executive, who is directly responsible for the client relationship and delivery of the assessment. Allowing the same individual to serve both roles would create a conflict of interest and undermine the credibility of the QA review. Instead, assessor organizations must designate separate personnel: the Engagement Executive to oversee project execution and a QA Reviewer to confirm accuracy, consistency, and compliance with HITRUST methodology. This separation supports objectivity and enhances the reliability of the assurance program.