In an r2 assessment, CAP requirements are determined at the Control Reference level. If the aggregate score falls below the certification threshold of 71, and the Implementation maturity level is not at 100%, a Corrective Action Plan (CAP) must be documented. This ensures that organizations commit to remediating critical control deficiencies before certification can be finalized. CAPs must include clear details such as responsible parties, remediation steps, and timelines. Without CAPs, HITRUST will not accept the assessment for certification. Even if Policy or Procedure scores are strong, missing implementation creates unacceptable risk. Therefore, HITRUST mandates CAPs in these cases to close certification-critical gaps.
References: HITRUST Scoring Rubric - "CAP Trigger Conditions"; CCSFP Practitioner Guide - "CAPs in r2 Certification."