- A
Conduct a vulnerability assessment of all cloud resources to identify and remediate security weaknesses.
Why wrong: Vulnerability assessments are good practice but not the first priority over incident response.
- B
Develop and implement a formal incident response plan that includes procedures for detecting, reporting, and responding to PHI breaches.
An incident response plan is a HIPAA requirement and addresses the identified gap.
- C
Implement customer-managed keys (CMK) for all Azure backups to ensure the organization controls encryption keys.
Why wrong: Key management is important but not the most critical compliance gap.
- D
Implement a data classification policy to label all data assets according to sensitivity.
Why wrong: Data classification is useful but does not directly address the lack of incident response.
Quick Answer
The answer is to develop and implement a formal incident response plan that includes procedures for detecting, reporting, and responding to PHI breaches. This is the correct first action because HIPAA’s Security Rule explicitly requires covered entities to have documented policies and procedures for managing security incidents involving electronic protected health information (ePHI); without this foundational plan, encryption and backup controls are irrelevant to demonstrating compliance during an audit. On the CCSP exam, this scenario tests your understanding of the HIPAA Security Rule’s administrative safeguards, which prioritize incident response over technical controls like encryption—a common trap is to focus on the backup encryption key issue, but the most critical gap is the missing process, not the key management. Remember the mnemonic “Plan Before Protect”: you must establish a formal incident response plan before worrying about key custody, because HIPAA audits first check for documented procedures, not just technical controls.
CCSP Legal, Risk and Compliance Practice Question
This CCSP practice question tests your understanding of legal, risk and compliance. The scenario asks you to isolate a root cause — eliminate options that address a different problem before choosing. After answering, compare your reasoning against the explanation and wrong-answer breakdown below. Once you have made your selection, read the full explanation to reinforce the concept and understand why each distractor is designed to mislead on exam day.
A large healthcare organization uses a hybrid cloud environment with on-premises systems and Microsoft Azure. They store protected health information (PHI) in Azure Blob Storage and use Azure SQL Database for transactional data. The organization must comply with HIPAA and has implemented encryption at rest using Azure Storage Service Encryption and Transparent Data Encryption (TDE) for SQL. During a recent audit, the security team discovered that the organization does not have a formal process to identify and respond to security incidents that involve PHI. Additionally, the organization's backup strategy stores encrypted backups in a separate Azure region, but the backup encryption keys are managed by Azure and are not customer-controlled. The compliance officer is concerned about the ability to demonstrate HIPAA compliance in the event of an audit. Which of the following actions should the organization take FIRST to address the most critical gap?
Clue words in this question
Noticing these words before you look at the options changes how you read each choice.
Clue:
"first"Why it matters: Order matters here. You are being tested on which action comes before the others — not which action is generally useful.
Answer choices
Why each option matters
Answer the question above first, then reveal the full breakdown to understand why each option is right or wrong.
Correct answer & explanation
Develop and implement a formal incident response plan that includes procedures for detecting, reporting, and responding to PHI breaches.
The most critical gap is the lack of a formal incident response plan for PHI breaches. HIPAA requires covered entities to have documented policies and procedures for detecting, reporting, and responding to security incidents involving ePHI. Without this plan, the organization cannot demonstrate compliance during an audit, regardless of encryption or backup controls.
Key principle: Answer the scenario, not the keyword: identify the specific constraint before choosing the most familiar-sounding option.
Answer analysis
Option-by-option breakdown
For each option: why learners choose it and why it is or isn't the right answer here.
- ✗
Conduct a vulnerability assessment of all cloud resources to identify and remediate security weaknesses.
Why it's wrong here
Vulnerability assessments are good practice but not the first priority over incident response.
- ✓
Develop and implement a formal incident response plan that includes procedures for detecting, reporting, and responding to PHI breaches.
Why this is correct
An incident response plan is a HIPAA requirement and addresses the identified gap.
Clue confirmation
The clue word "first" in the question point toward this answer.
Related concept
Read the scenario before looking for a memorised answer.
- ✗
Implement customer-managed keys (CMK) for all Azure backups to ensure the organization controls encryption keys.
Why it's wrong here
Key management is important but not the most critical compliance gap.
- ✗
Implement a data classification policy to label all data assets according to sensitivity.
Why it's wrong here
Data classification is useful but does not directly address the lack of incident response.
Common exam traps
Common exam trap: answer the scenario, not the keyword
ISC2 often tests the distinction between proactive security controls (encryption, vulnerability assessment, data classification) and the mandatory reactive compliance process (incident response plan) required by regulations like HIPAA, leading candidates to prioritize technical fixes over procedural requirements.
Detailed technical explanation
How to think about this question
HIPAA's Security Rule (45 CFR § 164.308(a)(6)) mandates that covered entities implement policies and procedures for responding to security incidents, including identifying and mitigating harmful effects. The incident response plan must include specific steps for breach notification under the Breach Notification Rule (45 CFR §§ 164.400-414), which requires notification to affected individuals, HHS, and sometimes the media within 60 days. Without this plan, even with strong encryption, the organization cannot legally demonstrate compliance.
KKey Concepts to Remember
- Read the scenario before looking for a memorised answer.
- Find the constraint that changes the correct option.
- Eliminate answers that are true in general but not in this case.
TExam Day Tips
- Watch for words such as best, first, most likely and least administrative effort.
- Review why wrong options are wrong, not only why the correct option is correct.
Key takeaway
Answer the scenario, not the keyword: identify the specific constraint before choosing the most familiar-sounding option.
Real-world example
How this comes up in practice
A developer is choosing between AES-256 (symmetric) and RSA-2048 (asymmetric) for encrypting a large file that will be sent to a partner. Symmetric encryption is fast but requires key exchange; asymmetric is slower but solves the key distribution problem. A hybrid approach — encrypt the file with AES, encrypt the AES key with RSA — is standard. Questions like this test whether you understand when each approach applies.
What to study next
Got this wrong? Here's your next step.
Identify which exam domain this question belongs to, review the core concept, then practise similar questions from the same domain.
- →
Legal, Risk and Compliance — study guide chapter
Learn the concepts, then practise the questions
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FAQ
Questions learners often ask
What does this CCSP question test?
Legal, Risk and Compliance — This question tests Legal, Risk and Compliance — Read the scenario before looking for a memorised answer..
What is the correct answer to this question?
The correct answer is: Develop and implement a formal incident response plan that includes procedures for detecting, reporting, and responding to PHI breaches. — The most critical gap is the lack of a formal incident response plan for PHI breaches. HIPAA requires covered entities to have documented policies and procedures for detecting, reporting, and responding to security incidents involving ePHI. Without this plan, the organization cannot demonstrate compliance during an audit, regardless of encryption or backup controls.
What should I do if I get this CCSP question wrong?
Identify which exam domain this question belongs to, review the core concept, then practise similar questions from the same domain.
Are there clue words in this question I should notice?
Yes — watch for: "first". Order matters here. You are being tested on which action comes before the others — not which action is generally useful.
What is the key concept behind this question?
Read the scenario before looking for a memorised answer.
About these practice questions
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Last reviewed: Jun 30, 2026
This CCSP practice question is part of Courseiva's free ISC2 certification practice question bank. Courseiva provides original exam-style practice questions with explanations, topic-based practice, mock exams, readiness tracking, and study analytics to help learners prepare for the CCSP exam.
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