HITRUST Updated CCSFP Exam Questions and Answers by raeya

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).

A Readiness Assessment Report is self-assessment–based and prepared with or without an assessor to help organizations identify control gaps.

The highest level of assurance is provided by a Validated Assessment Report, which undergoes external assessor validation and HITRUST quality assurance.

Therefore, a readiness assessment does not provide the highest level of assurance.

Extract Reference (HITRUST Assurance Program Guidance [0019]):

Readiness Assessments help identify gaps but do not provide certification or the highest level of assurance; only validated assessments do.

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.

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.