Fifteen men dressed in head-to-toe chocolate brown fill the dialysis unit's chairs.

Machines around the room buzz and whir, slowly filtering waste and fluid from the men's bodies, a job their failing kidneys can no longer handle.

A small television fleetingly captures one dozing man's attention. A prosthetic leg rests on the floor beside a nearby chair.

A white-haired man in a wheelchair stares blankly ahead, waiting for someone to push him back to bed.

It's almost time for the next count.

Despite his age and obvious infirmity, the man, like the others in the dialysis unit, is a state prison inmate.

But Laurel Highlands, tucked in the rolling hills of Somerset County, about 70 miles southeast of Pittsburgh, isn't like most prisons.

The minimum-security institution is the only one of the state's two dozen male prisons with a unit specifically designed to accommodate geriatric inmates and their health problems.

SLIDE SHOW: Inside Laurel Highlands

Laurel Highlands has 74 inmates with hypertension or diabetes severe enough to require dialysis. Men fill the chairs in three shifts on Mondays, Wednesdays and Fridays. Two more shifts come Tuesdays and Thursdays.

The prison's 104-person medical team also provides such advanced services as tuberculosis treatment and ventilator support. A hospice program serves inmates nearing the end of life.

"Is there anything we can't do here? Not really," said Annette Kowalewski, the prison's health care administrator. "If it's medically necessary, it gets done. Period. That's how we operate."

Geriatric care is increasingly necessary in the state prison system as the number of elderly inmates continues to climb, along with the costs of caring for them.

In 1980, there were just 370 elderly inmates in the state prison system, according to Department of Corrections statistics. By 2010, that number had swelled to 8,462.

It costs about three times as much to house, feed and care for an elderly inmate, according to a 2005 state government report.

The state considers prison inmates "elderly" at age 50. Inmates generally experience age-related health problems earlier than the general public.

"Here, 50 looks like 90," Kowalewski said. "They've abused drugs, they've not lived a very good life in terms of nutrition or where they're living. They age a lot more quickly internally."

Some 236 men and seven women sentenced in Lancaster County courts are part of the booming "elderly" state prison population.

Two dozen state inmates with local connections are at least age 65. The oldest include five men serving life sentences for some of the county's most notorious murders in recent memory.

John Askew, 80, George Burkhardt, 74, and Dale Healy, 67, were convicted in the 1979 Swarr robbery case, which led to the deaths of two elderly siblings. Roderick Frey, 74, and Grover Sanger Sr., 68, were found guilty in the killings of their wives.

The oldest female inmate sentenced in Lancaster County, 67-year-old Elizabeth Horn, pleaded guilty in the 2001 neglect death of Mary Ann Carney, her adult daughter who had a mental disability.

But many of the oldest inmates with county connections are sex offenders. Edward William Rawlings, 87, is the fourth-oldest in the entire state system.

Rawlings began serving a five- to 10-year sentence at Laurel Highlands in 2007, two decades after he repeatedly assaulted a young girl.

His defense attorney called the punishment "tantamount, essentially, to a life sentence."

Cost of care
Laurel Highlands, a former state hospital, opened as a prison in 1996. It is home to 1,200 inmates, 37 of whom were sentenced in Lancaster County.

The prison, like others in the state, is bursting at the seams. New modular units will house 150 inmates.

The men incarcerated here were convicted of murder, sex offenses and other crimes. The average inmate age is 44, the highest in the state system.

The average annual cost to house, feed and care for a state prison inmate is $32,986, which includes $4,737 for health care, Department of Corrections spokeswoman Susan Bensinger said.

Laurel Highlands' annual per-inmate cost is $45,993, or nearly 30 percent higher than the statewide average. That includes an average health care cost of $14,003, superintendent's assistant Betsy Nightingale said.

An inmate receiving long-term medical care at Laurel Highlands costs significantly more. In 2005, an advisory committee to the General Assembly's Joint State Government Commission reported that cost as $63,500.

Some 322 inmates live in the prison's medical unit, which offers both skilled and personal care. Many — but not all — are elderly.

Health care administrator Kowalewski said inmates in personal care "need to be reminded to take showers, [need] help cutting their food or getting their clothes back on. ... They can't walk long distances."

The prison medical staff includes 26 registered nurses, 42 licensed practical nurses and 30 certified nursing assistants — all state employees — along with four contracted physicians.

The U.S. Constitution guarantees prison inmates access to health care. In 1976, the U.S. Supreme Court ruled that "deliberate indifference to a prisoner's serious illness or injury" qualifies as cruel and unusual punishment.

State prison inmates can have surgery, chemotherapy and organ transplants. (Some acute problems may require outside hospitalization.) Inmates also get dental and vision care.

"If they need it, it's going to happen," Kowalewski said.

There is a referral process and a waiting list for state inmates to move to Laurel Highlands' medical unit. Some county prisons send their own seriously ill inmates.

Many inmates are not diagnosed with chronic health conditions, such as diabetes or hypertension, until they get to prison, Kowalewski said. That delayed diagnosis can increase the scope and cost of needed treatment.

The Department of Corrections' attempts to control skyrocketing health care costs include consolidation of specialized medical treatment services into "centers of excellence."

Inmates go to SCI Graterford, Montgomery County, for chemotherapy, and SCI Dallas, Luzerne County, for hepatitis C treatment, Bensinger said. Two other prisons provide short-term surgeries.

But some inmate advocates, including the Pennsylvania Prison Society, raise both humanitarian and financial objections to incarcerating elderly, infirm offenders at all.

"There are a number of people in the system who are very frail, very old, very sick," said Ann Schwartzman, the society's policy director. "They're not going to jump off of their beds and commit new crimes. They are no longer a threat to public safety."

Behind the walls
Laurel Highlands has housed men as old as 98. The oldest current inmate is 93.

The medical unit's four-man rooms resemble a dormitory — or a nursing home. At 10 a.m. on a recent weekday, some elderly men lie in bed, turning their backs to visitors or staring at the ceiling.

There are no bars on the windows. But there are grab bars on the bathroom walls for men who have trouble getting up.

The showers are equipped with seats. There are even shower tables for inmates who can't sit up.

Because so many inmates have mobility problems, the staff brings meals, alcohol rehabilitation and religious services to the unit.

Inmates wearing bathrobes play Scrabble and watch the History Channel in a day room. A man in a wheelchair talks on a pay phone in an adjacent hallway.

Many of the inmates appear too ill or elderly to cause much trouble. But the prison staff must balance care with security. A corrections officer guards the unit 24 hours a day.

"We do have problems," Kowalewski said. "It's not common, but it does happen."

In 2009, a 42-year-old inmate was charged with the rape of a nursing assistant in the medical unit, according to area media reports. Prison officials said it was an isolated incident.

Doors to inmates' rooms are not locked, but prison staff can activate automatic doors to quickly contain any problems, Kowalewski said.

Problem inmates can continue to receive care in a nearby restricted housing unit.

"Ninety-five percent of the gentlemen are very appreciative of the staff and know they're getting good care," Kowalewski said.

The end of the line
The balancing act between hospital and prison is never more delicate than when death is near.

A terminally ill inmate with time remaining on his sentence will almost certainly live out his days in prison. More than 400 men have died at Laurel Highlands since it opened in 1996.

Requests for medical (or "compassionate") release rarely are granted.

Three Laurel Highlands inmates have applied. One was denied, and the others died before a decision could be made.

About 150 inmates die in state prisons each year, Bensinger said. A disproportionate number of those deaths occur at Laurel Highlands, where at least 35 men have died so far this year.

The prison releases inmates' remains to their families. Unclaimed remains are cremated and buried in marked, numbered graves. Kowalewski knows of only 10 cases where remains went unclaimed since the prison opened.

Inmates who enter the skilled-care unit sign advance directives, she said. Terminally ill inmates may have more privacy and longer visits.

The prison's hospice program provides specialized nutrition, chaplain visits and other comfort measures. Inmate volunteers sit with those who are dying.

The program is expanding to four beds, due to demand.

"People die in prison regardless of what they've done," Kowalewski said. "That's not our concern.

"Everybody should have the ability to die with dignity."

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