Free Practice Questions for HITRUST CCSFP Exam

In HITRUST, scoring follows ahierarchical roll-up process. At the lowest level,Requirement Statementsare scored across the five maturity levels: Policy, Procedure, Implemented, Measured, and Managed. These individual requirement scores are then aggregated to produce theControl Reference score. Control Reference scores are averaged to determine theDomain 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.

In HITRUST assessments, certain maturity level scores may bepre-populatedin MyCSF based on scoping factors, inheritance, or framework defaults. However, these default entries arenot lockedand 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.

ForPolicy and Procedure maturity levels, HITRUST requires a minimum of30 daysbetween 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 beenapproved, communicated, and adoptedwithin 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.

HITRUST enforces strict evidence requirements to maintain credibility of assessment results. ForPolicy and Procedurematurity levels, if a score above 25% is claimed, the organization must link appropriate evidence (e.g., documented policies, standard operating procedures). ForImplementation, 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.

When performing HITRUST scoping, organizations must includeregulatory factorsrelevant to their operational and geographic context. Since this entity operates inMassachusettsandNevada, 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.

TheCMS Minimum Security Requirements (High)(B) would apply only if the entity processes Medicare/Medicaid-related data. TheTexas 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, onlyMassachusetts Data Protection ActandNevada Security of Personal Information Requirementsapply in this scenario.

HITRUST distinguishes betweengroupedandungroupedcomponents. 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 befunctionally 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 totest all components within scopeand cannot rely on sampling methods.

HITRUST certifications apply toimplemented 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 certifyproductslike 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 forpeople, 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 anorganization’s operational environmentas validated through a CSF assessment.

TheA1 Security Assessmentmodule evaluates the security, governance, and risk management ofartificial 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 likeHodgkin-Huxley(a neuroscience model) andBack 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.

Organizations that process sensitive information such as personally identifiable information (PII), protected health information (PHI), or payment card data must address numerous security and privacy challenges. These include regulatory compliance (e.g., HIPAA, GDPR, PCI-DSS), operational risks such as insider threats, and technical challenges like securing cloud environments, encryption, and access control. HITRUST recognizes these challenges as part of its rationale for developing the CSF. The framework consolidates multiple standards and regulatory requirements into a single certifiable model, helping organizations manage these complex obligations in a structured way. The assurance program then validates that organizations are applying these controls effectively. Because sensitive data is a primary target for cyber threats and regulatory scrutiny, organizations must account for layered protections, making the statementTrue.