Free HITRUST CCSFP Practice Exam with Questions & Answers | Set: 3

The HITRUST CSF integrates requirements from multiple authoritative sources (e.g., HIPAA, NIST 800-53, ISO 27001, PCI-DSS). However, the CSF does not replicate all requirements verbatim from each framework. Instead, HITRUST rationalizes, harmonizes, and normalizes these sources into a single unified framework. This means that overlapping requirements across standards are consolidated into common control references, reducing redundancy. Additionally, not every provision from an authoritative source is represented; instead, HITRUST includes requirements that are most relevant to information protection and compliance assurance. For example, PCI-DSS operational practices like business rules may not appear exactly as written, but their security objectives are captured within CSF control statements. Therefore, the CSF is comprehensive and risk-based, but it does not literally encompass every requirement word-for-word.

HITRUST defines sample sizes for manual controls based on their frequency of operation. For daily controls, such as system log reviews or daily backup checks, the required sample size is 25 items. This sample size is designed to provide sufficient evidence that the control is consistently applied over time while remaining manageable for assessors. For weekly controls, the sample size is smaller (5), and for monthly or quarterly controls, it is smaller still (2 or 1). The 25-item rule ensures daily processes are tested across a meaningful timeframe (roughly a month of working days) to validate reliability. This standardized approach ensures comparability across assessments and prevents under-testing.

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.

Readiness assessments, including the i1 Readiness Assessment, are not formally submitted to HITRUST QA. Instead, they are internal preparation exercises intended to help organizations identify gaps, plan remediation, and get ready for a validated assessment. QA reviews are reserved for validated assessments (e1, i1, and r2) that are submitted for certification or validated reports. Readiness results can be used by management or shared with business partners informally, but they are not validated by HITRUST. This distinction preserves HITRUST QA resources for validated assurance activities and emphasizes that readiness is an organizational self-assessment step.

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.

Unlike validated assessments, Readiness Assessments can be performed without a paid MyCSF subscription. HITRUST provides tools and options for organizations to conduct readiness reviews either directly in MyCSF (for subscribers) or through external assessor support without requiring a subscription. This flexibility allows organizations to test their preparedness and identify gaps before committing to the cost of a subscription or validated assessment. While subscription provides additional benefits (e.g., analytics, inheritance, reporting dashboards), it is not mandatory for readiness. This ensures that even smaller organizations or first-time users can access HITRUST readiness services without financial barriers.

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.

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).

HITRUST uses a scoring scale from 0 to 100, with categories for Fully Compliant, Mostly Compliant, Partially Compliant, Somewhat Compliant, and Non-Compliant. A score of 37 falls into the “Somewhat Compliant” category. This reflects significant weaknesses in Policy, Procedure, or Implementation maturity levels. Such a low score indicates a gap that must be addressed. Depending on whether the control is required for certification, HITRUST may require a Corrective Action Plan (CAP). CAPs are required when certification-critical controls score below thresholds (e.g., Implementation not at 100% where required). Therefore, a Requirement Statement score of 37 would be treated as a gap with a possible required CAP, depending on its criticality within the certification process.

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.