CCSFP HITRUST Exam Lab Questions

When performing scoping for an r2 assessment, HITRUST requires consideration of risk factors that tailor requirement statements. Four categories are applied: Technical, Organizational, Compliance, and Operational.

Technical Risk Factors consider measurable characteristics such as number of users, systems, or transactions, which directly influence the size and complexity of the control environment.

Organizational Risk Factors address the type of business, industry sector, and whether the entity is a covered entity or business associate.

Compliance Risk Factors incorporate regulatory drivers (e.g., HIPAA, PCI DSS, state laws) that generate additional requirement statements.

Operational Risk Factors consider how data is used, stored, and transmitted, including exposure points like internet-facing systems.

“General” and “Privacy” are not categories formally recognized in the HITRUST methodology. Privacy obligations are accounted for under compliance drivers such as HIPAA, GDPR, or state laws. These categories ensure that control requirements are right-sized to the entity’s unique environment, reducing both over-scoping and under-scoping.

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.

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.

Comprehensive and Detailed Explanation:

According to the HITRUST CSF Assurance Program, the reliance period for a point-in-time assessment is one year (12 months) from the assessment report date.

The statement claims a two-year validity, which is incorrect.

Reliance beyond one year would require an updated assessment or interim assessment for assurance continuity.

Extract Reference (HITRUST CSF Assurance Program, CCSFP Objectives [0078]):

Point-in-time reports can only be relied upon if issued within one year from the assessment start date; two years is not permitted.